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stakeholders, trust, uncertainty



  1. Montgomery, Kathleen


Reframing surprise as an opportunity rather than as a threat can be facilitated when we recognize that efforts to deny, control, and prevent uncertainty operate as barriers to reframing. Removing the barriers requires trust and risk-taking among key stakeholders, especially among patients, physicians, and health care organizations.


McDaniel, Jordan, and Fleeman make a compelling argument for reframing the way health care organizations view the unexpected-from considering surprises as unwelcome and dysfunctional to considering surprises as opportunities for creativity and learning. Given the special mission and the risks of unwelcome surprise in health care organizations, this may be easier said than done. In many types of organizations, the worst unwelcome outcome of surprise can be a poor bottom-line that leads to the organization's demise. In health care, the worst unwelcome outcome of surprise can be adverse health effects, including a patient's death. Thus, it is understandable that strong barriers to treating surprise as an opportunity rather than a threat have been erected and are sustained by various health care institutions.


At the same time, as McDaniel et al. emphasize, an inevitable element of "unknowability" exists in complex adaptive systems, so that predictability can never be fully achieved, and surprise can never be fully eliminated. Moreover, the human body is the epitome of a complex adaptive system, with unpredictable interactions of its internal components and unpredictable interactions of those components with its environment. The sources of surprise identified by McDaniel et al.-trajectories, bifurcations, self-organization, emergence, co-evolution-all have examples in the way the human body interacts with internal and external factors. Thus, it is provocative to consider seriously the possibilities of reframing inevitable surprise as an opportunity. To get there requires an understanding of existing barriers to surprise. McDaniel et al. note that held assumptions can block a manager's access to creativity and learning from surprise. In the following commentary, I elaborate on some of these held assumptions by important stakeholders in health care and how they have become embedded in institutions.