Top Leaders Sometimes Have to Get Out of the Way

Traditional top-down leadership is ill-suited to the changes required for accountable healthcare. Empowerment, also known as bottom-up leadership from frontline workers, may be the best route to organizational transformation.

Founding father Thomas Paine is widely but wrongly credited with saying, "Lead, follow, or get out of the way," to his fellow revolutionaries.

Yet despite the misattribution, the saying has staying power because it's a useful rallying cry for those who prefer action to endless deliberation and debate. It even has something to tell us about the transformation healthcare leaders are charged with engendering at their organizations these days, as they try to make a dramatic business shift from a volume-based model to a value-based one.

But in a touch of irony, CEOs might be better served not as the leaders or the followers in that maxim, but as those who get out of the way. As a leader of your hospital or health system—and for many of you, as the leader—you're used to providing the vision and asking your lieutenants to execute that vision. That's traditional top-down leadership, and there's nothing inherently wrong with it. But it's not the only way to lead, and in many instances, it's far from the best way. That's not just my opinion; more and more of you are telling me that in a new era of accountable healthcare, the CEO can't always say—to borrow from President Truman, who actually did say this—"The buck stops here."

In recent conversations with healthcare leaders, I'm hearing a word that nicely describes this leadership philosophy: empowerment. In this sense, empowerment is 180 degrees away from the top-down model, but it's still leadership. In fact, you might call it bottom-up leadership.

What these leaders mean when they talk about empowerment is that they're enabling others to lead, and they're getting out of their way. When I talk to CEOs about such things as removing waste from processes, they almost always reference their use of Lean, which relies on frontline workers to identify wasteful steps in providing care and which also relies on them to design better, more efficient processes. This is just one example of empowerment, or getting out of the way.

There are many ways to lead, but bottom-up leadership is counterintuitive because many don't consider it leadership at all. On the contrary, it takes a special leader to know that he or she doesn't have all the answers, and that those on the front lines of care—whether they're nurses or business analysts or registrars—might be best equipped to get your health system focused on driving out inefficiency.

It's amazing sometimes what it takes to see decisions get made in healthcare, which is one reason why so many agree that healthcare is so far behind other industries. In general, healthcare is so afraid to be bold—to make mistakes—that it defaults to the "way we've always done it."

That's not going to cut it in an era in which being nimble and taking risks will be rewarded, and where the overall revenue pie is shrinking. That isn't to say some big mistakes can't cost you your job, but inaction will do the same thing.

You know you don't have all the answers, and neither do your subordinates, but they know about their world, and they're more likely to have the right answer in those narrow areas than you are. Make them accountable for their decision, but let them make the call. That's the only way you'll be able, overall, to make the transformational process change that will prepare your organization for a much different business model.

Do some introspection. Maybe it's time to have to have a private conversation with yourself and realize the only way this is going to work is if you let your people try something and be okay with making mistakes here and there. If you can get to that point, you're well on your way to something other than leading or following—you'll be leading by getting out of the way.