Independence and Interdependence

This Monday America celebrates Independence Day, the day she declared independence from the British crown.   America’s founding fathers, of course, knew the importance of independence – that’s why they fought so hard to win it.  At the same time, they knew the importance of interdependence, both the interdependence of forging alliances among the colonies and the interdependence of maintaining alliances abroad.

We would do well to learn from America’s founding fathers and to apply their lessons to our institutions.   How can institutions, and the people who work in them, exhibit both strong independence and strong interdependence?

Virginia Mason Medical Center in Seattle knows the answer to this question.

In 2000, faced with the challenges of spiraling costs and quality control that the entire health care industry was encountering, Virginia Mason Hospital knew that it needed to change or die.  When the hospital created a strategic plan that reached clarity about its customer being the patient, the board responded to the leadership team with a challenge: “If the patient is the customer, why is everything designed around you, the doctors and nurses and staff, instead of being designed around the patient?”

Seeking an answer to this question led Virginia Mason’s leaders to the Toyota Production System, which had masterfully eliminated waste and put the customer first.  Virginia Mason’s leadership began to wonder how Toyota’s system might apply to health care.

Through a long process of exploring similarities and differences between health care delivery and the Toyota Production System, Virginia Mason leaders decided to adapt Toyota’s system to health care.

Central to the Toyota system were Rapid Process Improvement Workshops, in which interdisciplinary teams would observe health care processes from the patient’s perspective, identify ways in which the patient’s time was wasted, and design new processes that eliminated the waste.  Testing and refining the processes resulted in standardization, recognizing the interdependence of care providers and the importance of working together efficiently and effectively.

At first, this standardization and recognition of interdependence clashed with the strong independence of the physician culture.  Physicians, accustomed to autonomy, questioned the validity of standardization, claiming it would bring down the quality of care.  Some ridiculed the application of manufacturing processes to the practice of medicine.  Others left the hospital.

But over time, as physicians tested the new processes and discovered that they could serve more patients more fully, without having to work late or take work home, they began to understand their interdependence with the larger system in a new way.  They began to see with fresh eyes, valuing their independence in such areas as diagnosis and prescribing treatment, and valuing their interdependence within the hospital’s structures and processes.  Independence and interdependence could complement one another, resulting in better care for patients, dramatic lowering of costs, and less wasted time for patients and physicians alike.

When independence and interdependence balance one another within an institution, the institution thrives.  Finding the appropriate arenas for independence, while at the same time recognizing the places of interdependence, can help an institution’s ecology flourish.

This Independence Day, let’s take a lesson from America’s founding fathers and, following Virginia Mason’s example, strengthen both independence and interdependence in our institutions.

4 Responses to “Independence and Interdependence”


  1. 1 Michael Bischoff July 2, 2011 at 3:52 pm

    This reminds of the the attempts GM had in learning from Toyota’s more interdependent style of manufacturing, such as the NUMMI plant. It has been written about and reported on many places. In summary, the initial results were wonderful, but GM’s broader culture and the broader US culture strongly resisted the more interdependent Toyota style, and the collaboration eventually fizzled. The GM example reminds me to think of organizations seeking to act more interdependtly within the larger social change to integrate interdependence more into mainstream, Western culture. It is a long-term project, and institutions, like Virginia Mason, that move that direction can play a leadership role in the overall society.

  2. 2 Margaret Benefiel July 2, 2011 at 4:10 pm

    Michael, thank you for this example of GM. Yes, it is a long-term project, and Virginia Mason has spent over ten years changing its culture and challenging the broader US culture (not to mention physician culture) around it. I think that Virginia Mason (which was named one of two “Hospitals of the Decade” by the Leapfrog Group this past December) is playing a leadership role in health care culture and also beginning to play a leadership role in the overall society.

  3. 3 latetogod July 3, 2011 at 8:27 pm

    I loved reading this, Margaret, perhaps in part because I’m so intellectually committed to interdependence of all things. Yet I’m less familiar with how this relates to organizations and institutions, so I especially appreciate thinking about these connections. It seems like our willingness to change waits for our individual or our institutional “Change, or Die!” moments, and when I hear of change being poo-pooed, I — erroneously or not — come to the conclusion that those poo-pooers either will not or cannot change. And again, maybe erroneously, I imagine those unchanging facing newly defined death possibly or probably have crippling fears related to those impending deaths. I also suspect that other people’s unwillingness or inability to change some things does not signal their reluctance or lack of ability to change other things, as I suspect that my comfort with changing a few things lures me into thinking I am just fine, thank you, with all other change. My wife agrees there are a number of things I do not want to change, even though I think I’m pretty open to generic change. Thank you for posting this! (Personally, I’ve never written so much poo into ANY writing. Wow.)

    • 4 Margaret Benefiel July 4, 2011 at 5:51 am

      Good points. It’s easy to think that poo-pooers won’t change. At Virginia Mason, there were quite a few skeptics who gradually came around. And you are so right that we all find it easier to change in some areas of our lives than in others, and it is those closest to us who keep us humble by pointing out the areas in which we are reluctant to change. I find it very eye-opening (if occasionally irritating) when my husband does this for me. Thank you.


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