Healthcare executives are under enormous stress. Trying to improve quality and safety, increase access, and reduce costs is exhausting. There is great pressure to satisfy many conflicting and competing interests. One chief clinical officer says she feels that "the cliff is visible." Many people see the system as heading dangerously close to that precipice.
We all agree that deep systemic change is needed, and the gap between the current reality and where we want to be continues to widen. Yet many of the key parties behave as though they want their part in the current system to continue. This may seem counterintuitive. But our experience suggests the reason why people resist change is not from a lack of facts and analysis about the need for change; the resistance comes from strongly held values, beliefs, and practices within the various factions, precisely those who must engage if significant progress is going to be made.
Adaptive challenges and technical problems
Challenges fall into two categories. If the expertise to solve your challenges exists anywhere within the healthcare system, you are facing a "technical problem." To solve technical problems, you inform people about the priorities, define roles and responsibilities, and set standards for success. It's a matter of focusing existing competencies, aligning the participants, and holding them accountable for results.
The most common error is to apply existing protocols to "adaptive challenges," which are about values and beliefs, ways of being, and identity. Progress on adaptive challenges is not about prevailing logic or data. Instead, adaptive challenges require leadership behaviors that raise what practices and approaches you need to preserve and what you need to discard.
When you help people distinguish what is essential from what is expendable, you create space for the innovative approaches to take hold. However, this is dangerous.
Making this distinction generates resistance because it creates an experience of loss—the loss of what is familiar and comfortable, including expectations, priorities, rewards, or the values that guide everyday decisions. Diagnosing the type of challenge you are facing and identifying the potential losses in order to address the work directly is an essential first step of exercising leadership.
Here's one major adaptive challenge. The implementation of electronic health records or physician order entry systems is complex yet appears to be quite straightforward. The technology can be customized. However, it is not just a matter of data entry.
The information is most valuable when it conveys a story that cuts across specialties and transitions of care. Supporting these transitions is more about practices and communications than it is about converting paper into a digital format. You are dealing with a different kind of challenge. The work is about changing the mindsets, habits, and traditions of caregivers at each step in the patient experience with your system. This touches on deeply held beliefs and approaches about how care should be provided.
One medical director says "EHR is part of the solution, but not the solution. We need a cultural solution about the role of the clinician. We need to become more value oriented in how we approach the work."
Another framed it, saying "the adaptive challenge for IT is the coordination among clinicians, their responsiveness. It changes expectations and communication between the PCP and the specialists."
As the quotes above illustrate, the challenge is about changing the relationships, not just talking differently to each other, but interacting in new ways and identifying the type of medical care that is most effective and produces the greatest value.
Who should be delivering what kind of care? It is an exercise of leadership when doctors, nurses, and administrators figure out the right balance, discerning the essential activities that create value from the practices that don't. How can you help people address what is most important and face what they stand to lose? How can you identify and explain the loyalties and commitments that you are asking people to change? In the EHR example, the opportunity is to make choices about how caregivers will interact in the future. All involved face some potential loss: giving up patient contact, something that energizes them, or ways of working that are familiar.
For example, if pharmacists were to work more closely with patients to help manage the drug therapy, it would mean less patient contact for other clinicians. If these potential losses are left unexamined, then the status quo is held in place by the success patterns of the past, the values, and beliefs that are rooted in the organization's culture, preventing progress in the new context.
Orchestrating conflict
Engaging people to tackle their tough challenges defines the new leadership for healthcare. When you are dealing with adaptive challenges, you are engaging people to face up to the tough choices that improvement demands. Hold a stance of curiosity to explore what the key stakeholders care about and be prepared for the pushback. Relying solely on your authority to tell people what they need to do won't yield results. Any cardiologist, primary care physician, or nurse can attest to the success rate of "delivering the sermon" to their patients with heart disease about eating right, exercising, and quitting smoking.
The challenges right now for healthcare are daunting. When the situation calls for adaptive change, you are helping people navigate through a period of disturbance as they sift through what is essential and what is expendable. This disequilibrium can be a catalyst for you to ask people to operate beyond the default set of responses. With too much disequilibrium you will lose people's attention. Without enough disequilibrium, nothing happens.
No one faction owns the problem—not the administrators, specialists, hospitalists, payers, patients, employers, local governments, or the policy makers. While getting people to the table is important, no one will volunteer to give up the control, authority or expertise they now have. A significant part of adaptive work is getting people to focus and put consistent attention on the difficult issues at hand.
The system will begin to adapt when there is enough disequilibrium for all the salient factions to exhume and examine the conflicting priorities. Progress and adaptive change involves asking people to confront difficult issues in their domain and give up habits and beliefs they hold dear. Successful adaptation occurs when all factions participate, collaborate, and identify what they need to leave behind.
Progress on adaptive challenges requires the kind of leadership that breaks through the impasses, unveils the competing commitments, and confronts the legacy behaviors that prevent progress. This is a different kind of leadership for a system anchored in scientific training. Resist the temptation to tackle challenges by framing them to fit within a technical insight.
The cliff is near, and you are uniquely in a position to help and prevent your system from falling over it. You can develop the skills to diagnose the challenge and orchestrate the conflict. Adaptation is more than surviving; it is about mobilizing people and creating environments that are more robust and resilient, environments for people to thrive. With the right focus, you can engage people in adaptive work and nurture the new DNA that will promote wellness and healing that brings your organization into the future.
How can you take advantage of the opportunity to create enduring change in healthcare? Where will the leadership come from?
For many, the traditional paradigm of a "great leader" conjures images of famous CEOs, great presidents, or iconic battlefield commanders. That notion is not uncommon; and it is a dangerous assumption. Exercising leadership for adaptive work is not about directing others and telling them what to do. The work of leadership is both having the courage to face reality and helping the people around you to face three realities at once:
- What values do we stand for, and are there gaps between those values and how we actually behave?
- What are the competencies we have, and are there gaps between those resources and what the patient care demands?
- What opportunity does the future hold, and are there gaps between those opportunities and our ability to capitalize on them?
You don't have to answer those questions yourself. What well-structured questions can you raise, rather than offering definitive answers? Imagine the differences in behavior if you believed the idea that leadership means influencing the organization to follow the CEO's vision or if you operated with the assumption that leadership means influencing the organization to face its problems and to live into its opportunities.
Kristin von Donop is a principal with Cambridge Leadership Associates, a leadership consulting firm. She can be reached at kvondonop@cambridge-leadership.com.
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