Ecological resilience and crisis leadership in the COVID-19 pandemic
The COVID-19 pandemic has applied unprecedented pressure to health care systems around the globe and demanded dynamic adaptation of delivery and structure. In so doing, the pandemic has unmasked remarkable rigidity and, therefore, vulnerability in our systems. In this article, we explore concepts of systems resilience, in particular ecological resilience, and their application to crisis leadership, guided by conversation with Dr. Michael Gardam, chief of staff at Humber River Hospital, Toronto. Furthermore, we argue that resilient systems respect minimum specifications, breed innovation, and are diverse, engaged, and humble.
KEY WORDS: ecological resilience, systems resilience, complexity, health care system, leadership
CITATION: Kraus R. Ecological resilience and crisis leadership in the COVID-19 pandemic In conversation with Dr. Michael Gardam. Can J Physician Leadersh 2020;7(1):38-42.
As health care systems the world over bend to the continued onslaught of COVID-19, health care structure and delivery are undergoing dynamic changes. I sat down (virtually) with Dr. Michael Gardam, infectious diseases specialist and chief of staff at Humber River Hospital, Toronto, to discuss health leadership and innovation within this exceptional context. “You have to adapt,” Gardam says, referencing both the individual and the medical system. “If you’re not flexible, you break.” Top
Dr. Gardam has built his career and international reputation tackling systems challenges through the lens of complexity science, expertise that he offers as a consultant to hospitals and health organizations around the globe.1 His insights, reflected in conversational excerpts throughout this article, inspire a deeper dive into the behaviours of complex adaptive systems and their applications to health leadership, which we explore herein.
Complex systems and ecological resilience
Fundamental to a complex system’s capacity for adaptation is resilience. However, not all forms of resilience are equal across systems and circumstances. “In complexity science,” Dr. Gardam explains, “we talk about [ecological] resilience rather than engineering resilience. Engineering resilience, you spring right back to where you were before. [Ecological] is kind of like a tree growing against the wind — it starts growing differently because it’s adapting to the pressure.” Top
The concept of ecological resilience was introduced by Holling in 1973 to describe the “measure of the persistence of systems and of their ability to absorb change and disturbances and still maintain the same relationships between populations…” within natural ecosystems.2 This is balanced with stability, fundamental to engineering resilience, which he defines as the “ability of a system to return to an equilibrium state after a temporary disturbance; the more rapidly it returns and the less it fluctuates, the more stable it would be.”2
Ecological resilience rejects the notion of a single state of equilibrium. Rather, it proposes the existence of multiple equilibria in a single system and “the tendency for systems to ‘flip’ into alternative stability domains,” e.g., the transformation of a rainforest into a desert in response to changes in climate.3 Movement between stability domains maintains structure and promotes diversity to the ultimate benefit of the system’s survival.2
Although Holling initially described these concepts within an evolutionary framework, his ideas have since been applied to economic, organizational, and institutional structures. Moreover, he himself argued that “policies and management that apply fixed rules… lead to systems that gradually lose resilience and suddenly break down in the face of disturbances that previously could be absorbed.”4
The COVID-19 pandemic has unmasked the rigidity and, therefore, fragility of our health care systems. How, then, do we apply lessons of ecological resilience to the Canadian health care context in the midst of the greatest disturbance since the Canada Health Act? Let us examine the behaviour of resilient systems. Top
Resilient systems respect minimum specifications
Specifically in the health care context, ecological resilience can be described as “the magnitude of disturbance that can be absorbed before the system changes its structure in order to remain within critical thresholds” — maintaining standards of health care delivery, for instance.3 In their seminal 2001 paper, “Complexity, leadership, and management in healthcare organisations,” Plsek et al.5 argue that creative thinking within complex adaptive systems is born of “a few, flexible, simple rules,… so called minimum specifications,” or min specs.6 Moreover, they propose that min specs include four foundational elements conducive to innovation: direction pointing, boundaries (or critical thresholds, as above), resources, and permissions.5 Dr. Gardam knows their value well.
“I view the whole world [as a set of] min specs. What are the guiding principles you’re going to use? Everything you do has to be true to those guiding principles.”
Citing an application of min spec ideology in his leadership during the pandemic, Gardam describes a situation in which the hospital’s anesthesiology team deliberated the use of powered air-purifying respirators (PAPRs), a specialized form of personal protective equipment (PPE) employed during aerosol-generating procedures, such as endotracheal intubation. Top
“One of my guiding principles was [our] doctors have to feel safe…. A lot of our anesthetists were, frankly, really frightened…. So we started there. I said, ‘That’s the what, let’s start talking about the so what.’ How should we start approaching this rather than immediately jumping to a solution? Let’s start chipping away at it and look at different options that are available to us. And from that, start building our approach. Rather than just [a] knee-jerk ‘let’s go out and buy a bunch of PAPR hoods.’”
“I had my concerns whether [PAPRs] were the right solution for them, but I also felt [that] I’m not the guy intubating, so I’m not going to choose for them. We sat down, played with PAPRs for a while, and in the end, they decided that it wasn’t what they wanted. But imagine if I would have told them, ‘No, you can’t have them’. It would have been a disaster.” Thus, allowing for organic evolution within the boundaries imposed by min specs, Dr. Gardam cultivates the natural creativity of his team. Top
Resilient systems breed innovation
Subsequent to Holling’s introduction of the resilience conceptual framework, an evolving understanding of human and environmental interactions within systems led to the emergence of a new concept, socio-ecological resilience, which puts forth the theory that systems “are in a constant state of adaptation and flux, which is determined by the human capacity to learn, innovate and adapt.”3 From this arose the adaptive cycle metaphor, which seeks to describe how complex adaptive systems change over time.7 The cycle (Figure 1) is characterized by four phases that illustrate a continual, infinite process as succinctly outlined by Walker et al.8
The first is a phase of growth [exploitation or birth], characterized by readily available resources [or capital], the accumulation of structure, and high resilience. As structure and connections among system components increase, more resources and energy are required to maintain them. The second phase [conservation or maturity] is, thus, one in which net growth slows and the system becomes increasingly interconnected, less flexible, and more vulnerable to external disturbances…. Disturbances lead to the next phase [release or creative destruction], a period of release of bound-up resources in which the accumulated structure collapses, followed by a reorganization phase, in which novelty can take hold, and leading eventually to another growth phase in a new cycle. Top
When applied to human-natural systems (health care, for example), one can substitute “innovation” for “reorganization” in the model above. For the purposes of our discussion, we accept that the Canadian health care system is a complex adaptive system — we do not consider alternative conceptual frameworks, such as that proposed by Kurtz and Snowden10 (the cynefin framework and its “ordered” domains of simple and complicated, “un-ordered” domains of complex and chaos, and central domain of disorder) that allows for transitions or oscillations between domains.10,11
Having served as a consultant to a number of international organizations in complex health care environments, Dr. Gardam offers a pointed perspective on health care innovation in Canada. “To me,” he says, “the most obvious innovation to come out of COVID-19 has been virtual care. We’ve been talking about virtual care for decades. It took a very significant external event to push the system very hard. This is a classic burning platform. You can’t see your patients anymore. You don’t have any PPE. You’re terrified you’re going to get infected. And your patients still need to be cared for. What are you going to do? Within a matter of a few weeks, our whole mental health program shifted to entirely virtual.” Top
Before COVID-19, implementation of virtual care was slow-moving. “It’s why it’s so difficult to have disruptive innovation, especially in Canadian health care. It’s almost hard to have any innovation. We’re so conservative. Governments don’t like big risky projects, because if it doesn’t work, it’s a scandal, rather than ‘it didn’t work, brush yourself off, try again.’”
Here, Dr. Gardam describes a system stuck in a rigidity trap (Figure 1), a maladaptive departure from the adaptive cycle in which capital, connectedness, and resilience are concurrently high. That is, high resilience despite great capital and connectedness implies that the system is able to resist disturbance and persist, unchanged, “beyond the point where it is adaptive and creative.”12 Who, then, should drive health care innovation in Canada, and how might they escape the rigidity trap?
“[Doctors] have a lot of power. We’re… seen as part of the system, but kind of system-adjacent. There’s the health care system — and the doctors. There’s the hospital — and the doctors. Even our legislation keeps us separate. Use it to your advantage. Try really different things. Don’t ask for permission…. Push the envelope and get out there and try things. See where it takes you. It’s easier for [doctors] to be innovative than it is for the health care system to be innovative. If we have to wait until everything is perfect, we’ll never do anything.” Top
Resilient systems are diverse
Hollins2 further argues that, in contrast to engineering resilience and its prioritization of stability and predictability, a management approach based in principles of ecological resilience emphasizes “the need to keep options open… and the need to emphasize heterogeneity.” In other words, diversity leads to ecologically resilient systems.
“The way forward is to get groups together with divergent opinions, kicking around min specs, and then allow people to create what works for them,” says Dr. Gardam. “That’s the antithesis of how health care systems tend to work. Look at Ontario. Until recently, they didn’t want to use a regional approach to reopening in COVID. That makes no sense. Why would you treat Thunder Bay the same as Toronto?”
“That’s where I think diversity matters,” he continued. “Whoever has an opinion or thinks that a given issue is important should be at that table. And it may not be the usual suspects. You need to invite the unusual suspects.” Top
Resilient systems are engaged
At the time of our conversation, the epicentre of COVID-19 in Ontario was in the communities surrounding Humber River Hospital in northwest Toronto.
“There are clear reasons for that. It’s a marginalized population. These are the frontline service workers who live in crowded conditions…. So, what’s the solution to that? It’s not going to come from a middle-aged, well-off white doctor like me. It’s going to come from talking to the people who live there. But we don’t talk to the people who live there. We come up with government solutions in a conference room somewhere…. We need to actually engage the people who are in the middle of it.”
Citing her own experiment examining the impact of racial diversity on group decision-making, Dr. Katherine W. Phillips elegantly articulates the urgent need to engage different others: “Being with similar others leads us to think we all hold the same information and share the same perspective. This perspective… is what hinders creativity and innovation.”13
“Whatever problems we’re facing,” Dr. Gardam echoes, “we need to engage diverse groups. We need to listen to diverse opinions. And we need to take some risks.” Top
Resilient systems are humble
Finally, humility is central to resilience. A management approach based on resilience does not presume sufficient knowledge; instead, resilient management recognizes its own ignorance and assumes that future events will be unexpected.2
“When I started doing my consulting work, I realized that me as an expert was often not helpful at all. Me as someone who listens to people and empowers them to come up with their solutions: that’s where I was valuable. My knowledge was, frankly, irrelevant. That’s kind of the opposite of the medical model. I’m here to facilitate. I’m here to make it okay that you guys can figure out a solution for yourselves. I’m here to make that valid. That’s my leadership style. I’ve got some things that I need you to do [min specs], but I’m going to be very hands-off in terms of how you achieve that. I’m going to let you try things that I think won’t work, but what do I know really?”
Perhaps his most poignant statement, and an apt conclusion, Dr. Gardam closed with: “I have an opinion, but that doesn’t mean it’s right.”
I thank Dr. Gardam for his generosity of time, expertise, and humour. To so readily welcome discussion and provide mentorship is testament to his great leadership. Top
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9. Van Aerde J. Panarchy, the collapse of the Canadian health care system, and physician leadership. Can J Physician Leadersh. 2016;2(4):103-9. https://tinyurl.com/yxuent2e
10. Kurtz CF, Snowden DJ. The new dynamics of strategy: sense-making in a complex and complicated world. IBM Syst J 2003;42(3):462-83.
11. Van Beurden EK, Kia AM, Zask A, Dietrich U, Rose L. Making sense in a complex landscape: how the cynefin framework from complex adaptive systems theory can inform health promotion practice. Health Promot Int 2013;28(1):73-83. https://doi.org/10.1093/heapro/dar089
12. Holling CS. Understanding complexity of economic, ecological, and social systems. Ecosystems 2001;4(5):390-405. https://doi.org/10.1007/s10021-001-0101-5
13. Phillips KW. How diversity makes us smarter. Sci Am 2014;311(4):43-7. https://tinyurl.com/zo3asdr
Raphaël Kraus, MD, is a childhood vasculitis clinical research fellow in the Department of Pediatrics, Division of Rheumatology, Hospital for Sick Children. He is also an MSc candidate, System Leadership and Innovation, Institute of Health Policy, Management, and Evaluation, University of Toronto.
Author declaration: I have no conflicts of interest, nor have I received support in the form of grants or other industrial support relevant to this submission. The views expressed in this article are my own and are not an official position of any institution.
This article has been peer reviewed.