General Stanley McChrystal begins his book, Team of Teams, with the story of Spartan king Menelaus as he leads his men home from the Trojan War. They become shipwrecked and must confront the sea god Proteus. If the Spartans can defeat Proteus, he will reveal the secrets essential to their safe passage. But Proteus is a polymorph, a shape shifter who can remake himself and his environment. In confronting Proteus, the traditional ways and weapons of the Greeks provided little value. As Proteus shifted from serpent to panther to wild boar, then to rushing water and fire, the Greeks were compelled to adapt rapidly. And by so doing, they prevailed and found their way home.
McChrystal's use of a 3,000-year-old tale sets the stage for the message central to his book — we now face Proteus not only in warfare, but in many other spheres of life including health care. We need new structural strategies to meet the challenge of growing complexity.
On April 15, 2013, in an operating room at Boston's Brigham and Women's Hospital, reconstructive plastic surgeons E.J. Caterson and Matthew Carty faced their own Proteus. They were just finishing up a 10-hour effort to piece together the face of a 16-year-old skateboarder who had been hit by a car at 50 mph. A resident came in and told them a bomb had exploded downtown at the Boston Marathon. Caterson and Carty, accompanied by their surgical team, walked to the emergency room where other teams from around the hospital had already begun to converge.
Without knowing the extent of the carnage, they began to work with trauma surgeons, orthopedic surgeons and vascular surgeons to define treatment plans for the injured and triage them to the operating room. The teams that assembled had all collaborated in the past, but everything they would do that day was "a complete deviation from normal practices." There had never been a mass casualty simulation, no plan and no rehearsal. There was no time to wait for direction, and no plan could have anticipated the circumstances they faced.
The teams at Brigham and Women's that day responded by doing what they do every day — adapt. McChrystal observes that had they been bound by a hierarchical command structure, they would have been "too hidebound to respond effectively."
Responding to Emergence
McChrystal shares examples of adaptability by other teams including Navy SEALs as well as Captain Chesley Sullenberger's crew whose Airbus 320 landed in the Hudson River after a flock of Canada geese knocked out both of the plane's engines: "All of these teams were capable of adjusting to the unexpected with creative solutions on the spot, coherently and as a group. Their structure — not their plan — was their strategy."
McChrystal attributes this ability to respond effectively to "emergence," the tendency for complex patterns and forms to " … arise from a multiplicity of simple, low-level interactions … that allow order to emerge from the bottom up as opposed to being directed with a plan from the top down."
Today, emergent phenomena abound. A video can go viral and, in a matter of hours, ignite violent reactions worldwide. It can also generate constructive solidarity and action. And although such phenomena may be intentionally touched off by one person or a small group, unintended consequences occur, and they cannot be fully controlled once unleashed.
Al-Qaida in Iraq, or AQI, was McChrystal's Proteus. AQI comprised poorly trained and under-resourced fighters. Yet, they were, for a time, able to frustrate and outmaneuver the most advanced military machine on the planet. The key word is machine. Machines are designed for efficiency out of parts that are engineered to mesh and operate in predictable fashion.
AQI was not a machine. It was something fundamentally different — a network neither designed nor engineered. It was an emergent phenomenon well-suited to an environment that had shifted from complicated to complex. It consistently outmaneuvered and frustrated America's traditionally organized military hierarchy.
In confronting AQI, McChrystal began to see a need to distinguish between things that are complicated and those that are complex. Complicated things have many interrelated parts that are linked in discernible ways and operate in understandable and predictable fashion.
Complexity arises when there is a dramatic increase in the number of connections and interdependencies between things. Complexity wipes out any potential for prediction and efficiency. Complex systems exhibit a nonlinearity that can be paralyzing to leaders and managers accustomed to applying cause-and-effect assessments and methods. In complex systems, it is impossible to link effects with their causes and likewise impossible to predict when a seemingly innocuous cause might set off an explosive chain of interrelated effects. AQI and the environment in which it operates were complex. Only in 2003, when McChrystal began to remake the Joint Special Operations Task Force he led to reflect the decentralized network represented by AQI, did progress emerge.
A Million Permutations
Even situations that can be visualized readily and are constrained by easily understood rules, connections and interdependencies can generate significant complexity. McChrystal offers the example of chess. The rules, roles and relationships of the game are relatively straightforward. But experts suggest that there are 197,742 different ways for the players' first two turns to proceed. By the third move, the number of possibilities rises to 121 million, and by move 20, it is likely the game is unfolding in a way that has never been played before. But AQI offered an even more complex challenge. Chess is rigidly iterative with opponents alternating their moves. AQI could make multiple moves simultaneously.
McChrystal ties the development of the contemporary American military machine that faced the emergent AQI network to the "scientific management" philosophy pioneered by Frederick Taylor. Taylor was arguably the most influential management expert of the 20th century. He focused on transforming manufacturing with machinelike efficiency and productivity, and he promoted a rigid application of time and motion methods. Taylor was an evangelist who saw his philosophy as universally applicable to factories, schools and even home life. Peter Drucker, the "founder of modern management," once suggested that without Taylor's principles, America would have lost World War II to the Nazis.
Beginning in the early 1900s, Taylor's principles began to reshape modern society including the American military machine. A century later, that machine initially hit the wall when it encountered AQI's network. Complexity was sand in its gears. So McChrystal began to transform the machine. Not in bold sweeping moves but iteratively by learning and adjusting as the task force struggled with AQI and a complex environment.
A shift was needed from the operational focus on efficiency promulgated by Taylor. Efficiency, while still important, had to be supplemented by adaptability and resilience. "Resilience thinking is the inverse of predictive hubris," McChrystal observes. "It is based in a humble willingness to ‘know that we don't know' and ‘expect the unexpected' — old tropes that often receive lip service, but are usually disregarded in favor of optimization."
Throughout history, maps have been vital tools for generals. But maps are static and lose their utility when the environment they attempt to depict is in motion and mutable. The task force needed a different way to see its environment. So, as McChrystal reflects, "In place of maps, whiteboards began to appear in our headquarters. Soon they were everywhere. Standing around them, markers in hand, we thought out loud, diagramming what we knew, what we suspected, and what we did not know.
"We covered the bright white surfaces with multicolored words and drawings, erased, and then covered again," McChrystal recalls. "We did not draw static geographic features; we drew mutable relationships — the connections between things rather than the things themselves." What emerged on the whiteboards required " … a fundamental rewriting of the rules of the game. To win, we would have to set aside many of the lessons that millennia of military procedures and a century of optimized efficiencies had taught us."
Connecting the Teams
When McChrystal considered the machine underpinning the task force, he saw a proliferation of siloed teams lacking in connections and interdependencies. He realized he needed to somehow transform these teams into a networked "team of teams." While McChrystal acknowledges that teams have proliferated in all manner of organizations, they tend to operate within traditional hierarchies captive to Taylor's paradigm, and this has limited their ability to adapt and be resilient. Key to the development of a team of teams was a "scaling up" of characteristics usually found only at the level of small teams: trust, common purpose, shared awareness and the distributed authority to act.
Scaling up into a team of teams required recognition of dynamics that, unless addressed, would constitute potentially insurmountable obstacles such as the tendency for mistrust and miscommunication to generate breakdowns between teams. This is a central challenge addressed in the book: moving from a collection of small potentially disparate teams to a broad structure that was unified at both the macro and the micro level.
The late Harvard sociology professor J. Richard Hackman suggested that teamwork is a much bigger challenge than we tend to believe. "It's a fallacy," Hackman argued, to think "that bigger teams are better than smaller ones because they have more resources to draw on. As a team gets bigger, the number of links that need to be managed among members goes up at an accelerating, almost exponential, rate."
The inherent friction between teams that stand in the way of building a broader team of teams was described by a Navy SEAL in the following way: "That other squadron sucks, the other SEAL teams suck and our Army counterparts definitely suck." There are anthropological roots for the "everyone else sucks" phenomenon. British anthropologist Robin Dunbar has theorized that the number of people an individual can trust ranges from 100 to 230. In larger organizations, this leads invariably to a kind of tribalism.
Small teams stacked in a command structure of silos robbed the task force of adaptability and resilience. But leaving teams to their own devices would limit the ability to create much needed coordination. The challenge was one of scaling up " … trust and purpose without creating chaos."
Within individual teams, every individual could get to know other team members, yielding the trust and shared awareness needed to sustain a common purpose. Doing so was easy within a single team, but impossible with separate teams comprising thousands of individuals. What McChrystal discovered and operationalized were linkages between teams that allowed " … everyone to know someone on every team so that … they envisioned a friendly face rather than a competitive rival."
Trust and Purpose
"Joint cognition," the ability to think and act as a unit, is key to the competitive advantage of teams. A room full of computers networked to operate in parallel can begin to emulate a super computer capable of solving very large, complex problems that would overwhelm any single computer. But, according to McChrystal, the key is not the number of computers but the nature of their integration. Realizing the potential of a team of teams required " … the wiring of trust and purpose."
Trust and purpose require robust communication. In a complex environment, communication must be continuous. For McChrystal, this required the retooling of a standard military practice called O&I [operations and intelligence]. "The most critical element of our transformation — the heart muscle of the organism we sought to create and the pulse by which it would live or die — was our operations and intelligence brief … we invested in bandwidth to enable us to reach every component of our force and our partners, from austere bases near the Syrian border to Central Intelligence Agency headquarters at Langley, Va.
"Satellite dishes, from small to huge, connected the force," McChrystal explains. "Secure videoconferences, chat rooms, a Web portal, and email became key arteries of our circulatory system. Technically, it was complex, financially it was expensive, but we were trying to build a culture of sharing." To reinforce the importance of the O&I, it was never canceled and attendance was mandatory.
Initially, the challenge was to get everyone engaged when there was no explicit authority to compel participation. But McChrystal found that if enough battlefield success could be generated, people would want to participate. He observed, "O&I attendance grew as the quality of the information and interaction grew. Eventually, we had 7,000 people attending almost daily for up to two hours."
McChrystal ensured that the O&I was interactive. Participants were allocated four-minute slots to share important information. Typically, only the first minute was dedicated to an "update," and the remaining three minutes were filled with open-ended conversation with the briefer and others on the network, including senior leaders. "The responses to this type of interaction created new insights, deepened the group's understanding of a complex issue, and highlighted the deep levels of understanding of our personnel around the globe … . By having thousands of personnel listen to these daily interactions, we saved an incalculable amount of time that was no longer needed to seek clarification or permission."
Although it was the team of teams that allowed the task force to achieve results, leadership remained vital. McChrystal found that, " … only the senior leadership could drive the operating rhythm, transparency and cross-functional cooperation we needed. I could shape the culture and demand the ongoing conversation that shared consciousness required."
Cohesive and Agile
Distilling McChrystal's experience of building a team of teams comes down to cultivating two overarching organizational characteristics: shared consciousness and empowered execution. "Shared consciousness," he suggests, "is a carefully maintained set of centralized forums for bringing people together. Empowered execution is a radically decentralized system for pushing authority out to the edges of the organization. Together, with these as the beating heart of our transformation, we became a single, cohesive unit far more agile than its size would suggest."
As I read Team of Teams, I couldn't help but consider the implications of its message for health care. Today, more than ever, health care organizations need to become cohesive and agile. Although largely unrecognized by most of those who try to lead and manage it, health care has long been characterized by complexity; the reason for this centers on the very object of its concern — the human organism. It is no species' conceit to suggest that human beings are the most complex things yet uncovered. Embodied in their structure are connections and interdependencies that give rise to a level of complexity no organization comes close to approximating.
The human organism is infinitely variable at the micro level. Repairing it and maintaining it is far removed from making sure the doors on a Ford fit, and changing the oil regularly; in this reality can be found the roots of frustration often voiced by physicians when confronted by the chorus of cries for standardization of care. As surgeon Matthew Carty observed and too many health care policymakers and executives ignore, "Every patient is different. Nobody has an identical fracture. Operations are unpredictable. You always have to adapt."
Deploying traditional efficiency-seeking hierarchies and structures against illness, injury and wellness holds the potential not only to be ineffective, but also counterproductive and perhaps even dangerous — which makes McChrystal's story even more important. If pushing back al-Qaida in Iraq required a decentralized, empowered team of teams unified by common purpose and trust, it follows that pushing back disease and its costs, financial and societal, will require the same.
Not only is the human organism itself complex; it operates in complex interaction with a complex environment. McChrystal recounts a conversation with an immunologist regarding the similarities between human infections and state insurgencies: " … while neither HIV nor AIDS kills anyone outright, the human body is weakened to the point where it is fatally vulnerable to otherwise nonthreatening infections. The environmental factors that weaken the host indirectly strengthen and empower attackers … . I began to realize that an organization's fitness — like that of an organism — cannot be assessed in a vacuum; it is a product of compatibility with the surrounding environment."
Unpredictability in Health Care Reform
Of course, complexity extends beyond the operating room into all manner of health care decision-making and action, including politics and policy-making. For example, health care reform has been purposeful. Its intent has been relatively clear, at least as it is reflected in public pronouncements. If successful, reform will broaden the insured population and expand access to care while enhancing the value of that care.
But reform has been unleashed in an environment at least as complex as that faced in Iraq. So, the potential for unintended consequences is exceedingly high. When the federal government first began aggressively pumping money into health care in the '50s, it set off unintended consequences that we're compelled to confront today. Chief among these have been dramatic cost increases and lack of accountability.
As McChrystal recounts, Frederick Taylor drew a sharp line between those who manage and those who work — between thinking and doing. I would argue that in health care, a similar line was drawn with equally detrimental effects. That line was between management and medicine. Management was ceded to a professional class of administrators, while physicians, who were plenty busy with patients, were happy to stay focused on medicine.
Much attention is given to the impact of silos in health care. But the line drawn between management and medicine represents one of the mothers of all silos — a "macro silo" versus the "micro silos" that exist related to departments, divisions, specialties and locales. Only now is the wall between management and medicine being pulled down as more and more physicians are invited to participate in leadership and management decisions. McChrystal's redesign of the O&I holds valuable implications for health care leaders who face the challenge of engaging hundreds of physicians and generating results that enhance value.
Among McChrystal's conclusions is that attacking complexity with big data will result in failure. This is a particularly important warning for health care where so much attention is being shifted toward analytics as the industry's latest silver bullet. It's obvious to those on the receiving end of a big data fire hose that absent an ability to discern and apply useful patterns, data lead to just more noise. And it can be deafening.
Complexity undercuts the promise of big data because data, like other elements in a complex system, is interdependent. And this interdependence makes it virtually useless for purposes of prediction. Observes McChrystal about the experience of battling AQI, "Gaining understanding is not always the same as predicting … . In a simpler world, our leaps in data would have been of great predictive value, but the reality of increased complexity meant that when it came to foresight, we were essentially chasing our own tail — and it was getting away from us … . We have moved from data-poor but fairly predictable settings to data-rich, uncertain ones."
An Unceasing Task
While the Spartans' success in overcoming Proteus and the physicians' response to the Boston bombing are illustrations of the power of adaptability and resilience, they are also, in important ways, fundamentally different from the challenge that faced McChrystal in Iraq, because they were experienced as episodic. Once Proteus was overcome and Boston victims treated, the crisis seemingly passed even if its underlying causes survived. The threat McChrystal faced remained and it continued to morph. Today, growing numbers of organizations face similar ongoing complexity rather than episodic crisis.
In at least one other essential way, the task force's position was much different from that facing most leaders today. The stakes were higher. Despite the thousands of pages dedicated to executive suite courage and heroics, the players on the corporate stage generally go home and sleep safely in warm beds at night.
For the task force, mistakes and miscues were likely to cost lives as well as endanger the security of a region and potentially that of the home front. This is a difference health care shares with the American military if the prospect of lives saved and improved is considered as well as the lives threatened. The Institute of Medicine has, of course, illustrated the cost of medical errors by equating them with the crash of four jumbo jets a week.
Two more vital lessons began to emerge in the early summer of 2014 — four years after McChrystal left command. Sunni fighters, under the banner of the Islamic State of Iraq, began to surge across the territory that previously had consumed the task force's attention and that had been secured at the cost of many lives. The first lesson is that " … the constantly changing, entirely unforgiving, environment in which we all now operate denies the satisfaction of a permanent fix." The second is that " … an organization must be constantly led or, if necessary, pushed uphill toward what it must be. Stop pushing and it doesn't continue or even rest in place; it rolls backward."
McChrystal's Team of Teams is rich in ideas and lessons. It is one of the best books published in many years on organizational strategy and offers a powerful recipe for configuring and linking people to meet growing complexity. What emerges is an approach that deserves careful consideration and emulation by others who are faced with the challenge of leading in a rapidly shifting and unpredictable environment. In other words, it holds lessons for all of us.
Contributor's note: General McChrystal shares authorship of Team of Teams with Tantum Collins, David Silverman and Chris Fussell.
Dan Beckham is the president of The Beckham Co., a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN Daily.