Health care leaders as agents of change

The pace of change is accelerating in a hyperbolic fashion and is predicted to reach the point of singularity in the first half of the 21st century. (1)

At the point of singularity the rate of change tends towards the infinitely rapid. The pace of change may in fact be progressing exponentially. With regards to health care, it means that the amount of change experienced in the last nine years will quantitatively occur again in the next three, and then again in the square root of three and so on.

For this reason, success equates with adaptability. Because of this accelerating pace of change, we now live in a world where innovation and creativity are more important than perfectibility, (2) and where, as Will Rogers has stated, even if you are on the right track, you will get run over if you're not moving fast enough.

The sustainability of health care organizations demands that its leadership skate to where the puck is going to be! There are significant implications of this necessity.

What percentage of people sees excitement and possibilities in transformational change--not evolutionary changes, but revolutionary change? The dissemination of innovation model would suggest no greater than 15 percent. (3) The trait that characterizes innovators and early adopters is a capacity for risk taking, and the majority of people are risk averse.

All groups act to defend the status quo. When leaders propose to shift the paradigm that currently favors the dominant coalition within the group, the group will act to reject the proposal. (4)

For this reason, in times of transformational change it is impossible to lead by consensus. That's the huge paradox. In times of transformational change, especially in the absence of shared, imminent and serious threat, you cannot lead by consensus. You must lead to critical mass. Heretics create change! In these situations, leaders are rejected by the very constituency that they seek to serve.

Leading others

How then might an individual seek to successfully lead others in a world of discontinuous change, where the future is unknowable?

First, it is imperative to formulate pluralistic strategies. Where the future is so unknowable, it is critical not to bet the farm on a single strategy. Robust adaptive strategies willingly sacrifice the focus, apparent certainty, efficiency and coordination that traditional strategies provide for the sake of flexibility and a higher probability of success. (5)

Because resources are limiting, you must create new types of relationships that can help position the organization for multiple potential future realities. Many of these relationships will be virtual relationships and will involve non-traditional partners.

Secondly, it is essential to distinguish substance from form. With the world transforming ever more rapidly, it is imperative that you identify the essence of who you are and what it is you do, and separate that from the form in which it is currently being manifest.

Ideally, the former should remain immutable, while the latter will ever more rapidly be rendered historical artifact. If you are what you do, and you don't, then you're not!

Thirdly, build creative tension. Creative tension exists when an idealized vision for the future can be juxtaposed to an honest assessment of current reality. The tension created by the distance between the two produces movement in the direction intended. (6)

For this to take place, it is imperative to have an irresistible, inspiring and measurable dream. In this context, it is important to distinguish negative vision from positive vision.

Negative vision seeks to make something go away. "If we don't act now, something unwanted will happen." Negative visions are never sustaining because actions designed to limit an impending threat simultaneously lessen the magnitude of that threat and thereby the power of the need to continue to act. So, responding to a negative vision creates a saw tooth pattern of response where action occurs only when the intensity of the stimulus reaches a critical level.

Negative visions have relevance through influencing the timing of change. It is why identifying a common enemy is a meaningful ingredient of successful change initiatives. (7) Positive vision, on the other hand, seeks to create something new, to bring something into being. Only positive visions are sustaining.

It is equally important and often more difficult to truly clarify the present situation. It is especially difficult if the organization is currently successful in the dominant paradigm. The future never hits organizations between the eyes; rather, they get hit in the temple. It is why good is the enemy of better and why current success renders organizations especially vulnerable.

Transformation

What motivates the transformational leader who risks being rejected by his or her constituency?

Such leaders are driven by a moral or ethical imperative. They forsake a transactional leadership style in pursuit of something that must be done in and of its own right. For the transformational leader, the pain of leadership is exceeded only by the pain of lost potential.

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Transactional leadership, on the other hand, reflects the political exchange of resources, and is dominated by the coalition that possesses the most resources as measured in the current paradigm. (8)

There is a huge price to be paid by the transformational leader. It takes immense courage to challenge the vested interests of the dominant coalition that is threatened by ideas that shift the paradigm. It is also painful to be rejected by those whom you would seek to lead. Prophets do not often enter the Promised Land! But then, to the prophet, the journey is more important than the destination.

Fourthly, think slinky! Most health care organizations are managed to achieve consensus. Metaphorically speaking, if the organization were a slinky, consensus management would seek to push the slinky forward from behind. In such a model, the pace of change is determined by the slowest moving components.

Transformational change is accomplished by pulling the front elements of the slinky, and the developing tension pulls the remainder forward in their own time. This reflects leading to critical mass.

Critical mass is empirically defined as the square root of N. (9) In a population of 100 individuals, leadership by consensus would require at a minimum, convincing 51 members. Leadership by critical mass would suggest change could be accomplished by convincing 10. But, it has to be the right 10.

Intuitively these 10 are obvious. In his book, The Tipping Point, Malcolm Gladwell identifies three types of people who have disproportionate impact on influencing their peers. These are people who are either well-connected, serve as mavens, or act as salesmen.

1. The first are individuals who act as communication nodes for the spreading of information.

2. Mavens are knowledgeable individuals who delight in sharing that knowledge with others without seeking personal gain.

3. Salesmen are in many ways the most important. These people have the capacity to emotionally influence their constituents. They have presence or charisma, and easily influence others through their capacity to express and elicit common emotions.

As I reflect on the state of today's health care leadership, I find that those individuals who have had the greatest impact are the ones who have let go of the consequences of that leadership. That is, rather than play it safe by reacting to consensus opinion, they have chosen to passionately lead to a transcendent vision.

In essence they have rejected the politics of transactional leadership, and taken a position in service of what to them is a moral or ethical imperative. Paradoxically, in letting go of the consequences of leading to a transcendent vision, they have inspired their followers and allowed them to reconnect to the meaning and purpose in their work.

Disconnect

I agree with Robert Quinn (11) and personally believe that the malaise that characterizes the health care professions today is a result of the disconnection of what people do on a day-to-day basis from what it is that they care most about.

People are drawn to a career in health care primarily because they want to be of service to others. It is fundamentally a calling. However, economic pressures and progressive specialization have prompted physicians to see patients in transactional rather than transformational ways.

In effect, many physicians have mortgaged the doctor+patient relationship in deference to a doctor/disease or a doctor/technology relationship. I would suggest that technical interventions, no matter how expertly applied, in the absence of human context are singularly without joy.

I don't know any nurse who chose to enter nursing school because she or he desired to learn how to document. Many nurses report that they spend a majority of their time with the chart or at the computer, rather than at the bedside.

And, the flight of talent from the administrative side of health care is in large measure a reflection of the overwhelming focus on margin to the neglect of mission.

Arguably the two most influential business books published in the last decade were both authored by Jim Collins. Built To Last, (12) co-authored with Jerry Porras, sought to appreciate what distinguished the sustainability of highly successful businesses. The essential conclusion was that in these sustainable and highly successful companies the business plan only served as a vehicle for the core ideology of the workforce. The core ideology was defined as the sum of the shared purpose and values of the workforce.

In Good To Great, (13) a book that used similar research methodology to distinguish excellent performing companies from good performing companies in the same business, excellence was characterized by the metaphor of getting the right people on the bus, getting the wrong people off the bus, putting the right people in the right seats on the bus, and then deciding where the bus was going to go.

Both sustainability and excellence are derivatives of successfully managing the intangibles by allowing people of shared purpose to engage in work that matters.

The phrase, "no margin no mission" has truly done a disservice to health care. In disproportionately emphasizing the tangible aspects of the enterprise, health care has lost its soul. It is the primary responsibility of leadership to author the organizational vision. Leadership is about inspired followers.

Viktor Frankl in his book, Man's Search For Meaning, (14) concluded that the essence of the human experience is mattering. It is finding meaning and purpose in life, a desire to make a difference. When this is neglected the default position is a focus on economic self-interest.

I would argue that it is never about the money. When it becomes about the money, it is because there hasn't occurred the dialogue in which the more important values have been identified and prioritized.

When a person's primary values aren't being nurtured, the default position becomes money. However, extrinsic rewards never motivate. They in fact actually erode both the quality and the quantity of the work performed. (15)

When we can put the soul back into health care, when those in health care can reconnect what they do with what they most care about, then the joy will return, and tangible results will show up at the front door.

It is the job of leaders to create that environment. In a world of exponential change, where leaders must serve in the capacity of change agent, transformational leadership is paramount. It is a position of great risk, requiring courage and can only be successful when driven by the passion of a transcendent vision. It is imperative to find joy in the doing, to make the journey and destination the same.

As health care futurist Joe Flower has said, surfers don't do all that work just to get to shore.

References

1. Russell P. Waking Up In Time: Finding Inner Peace in Times of Accelerating Change. Novato, California, Origin Press, 1998.

2. Kelly K. New Rules for the New Economy: 10 Radical Strategies for a Connected World. New York, Penguin Group, 1998.

3. Rogers EM. Diffusion of Innovations. New York, Free Press, 1995.

4. O'Toole J. Leading Change: Overcoming the Ideology of Comfort and the Tyranny of Custom. San Francisco, Jossey Bass Publishers, 1995.

5. Beinhocker ED. "Robust adaptive strategies." Sloan Management Review 1999 Spring; 40(3).

6. Fritz R. The Path of Least Resistance: Learning to Become the Creative Force in Your Own Life. New York, Fawcett Columbine, 1989

7. Kotter J. Leading Change. Boston, Harvard Business School Press, 1996.

8. Goleman D. et al. Primal Leadership: Realizing The Power Of Emotional Intelligence. Boston, Harvard Business School Press, 2002.

9. Atchison TA and Bujak JS. Leading Transformational Change: The Physician-Executive Partnership, Chicago, Health Administration Press, 2001.

10. Gladwell M. The Tipping Point. How Little Things Can Make A Big Difference. Boston. Little Brown and Company, 2000.

11. Quinn R. Deep Change. San Francisco, Jossey Bass Publishers, 1996.

12. Collins J. and Porras J. Built to Last: Successful Habits of Visionary Companies. New York, Harper Collins Publisher, 1997.

13. Collins J. Good To Great: Why Some Companies Make the Leap ... and Others Don't. New York: HarperCollins, 2001.

14. Frankl VE. Man's Search for Meaning. New York, Pocket Books, 1984.

15. Woods M. "Creating a value chain of personal leadership in medicine." Click Online Medical Management Magazine, Oct. 2001.

By Joseph S. Bujak, MD, FACP

Joseph Bujak, MD, FACP, is vice president of medical affairs for Kootenai Medical Center, Coeur D'Alene, Idabo. He focuses on the reorganization of the provider community and the redesign of health care delivery. Bujak can be reached at 208-666-2014 or jbujak@attglobal.net

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