Leading Adaptive Change Val Ulstad, MD, MPH, MPA There are three kinds of organizations: those that make things happen those that wait for things to happen and those that wonder what happened? -anonymous 3 4 5 6 Reflex mechanisms evolved to protect us from our biggest threat Major threat or strain = hemorrhage due to trauma • Activation of neurohormonal and sympathetic nervous system • Elevated catecholamines • Salt and water retention • Maintain BP • Restore blood volume • Perfuse vital • Vasoconstriction organs 7 Vicious Cycle of Heart Failure Decreased cardiac output Elevated catecholamines Salt and water retention Activation of neurohormonal and sympathetic nervous system Vasoconstriction 8 Vicious Cycle of Heart Failure Decreased cardiac output Elevated catecholamines Salt and water retention Reflexes make things worse Activation of neurohormonal and sympathetic nervous system Vasoconstriction 9 The Heart of Health Care Is Relationship 10 The reason to change is to create a better future—but it is • stressful • draining 11 The heart of health care is… …breaking under the strain of the pace of change 12 Decreasing reimbursement Being rewarded for value not volume End of fee for service to bundled payments Accountable care – integration of hospitals and clinicians Focus on reducing readmissions Transparency in cost and quality Evidence based care Accountability for patient experience Regulatory search for waste, fraud and abuse 13 Emphasis on context • Productivity Meaningful/rewarding • Draining Trust • Suspicion RELATIONSHIPS STRAINED BY CHANGE Connection • Fragmentation Infinite potential • Finite resources Collegiality • Competition 14 The Failing Heart of Health Care Strain of change Suspicion Anger Withdrawal Fear 15 A Specialist’s Fear Fear • My expertise and training will not be valued • I have given up control and still have the responsibility to assure best care • I will have to work harder to make less money Anger, suspicion and withdrawal • I do not have time to spend more time talking to others • I am exhausted and have nothing left for my family • I don’t know who to trust More Strain • I withdraw and keep my head down hoping this will all go away 16 A Primary Care Clinician’s Fear Fear • My expertise and training will not be valued • I have given up control and still have the responsibility to assure best care • I will have to work harder and I am already tired Anger, suspicion and withdrawal • I do not have time to spend more time talking to specialists and negotiating boundaries of responsibility with them • I am exhausted and have nothing left for my family • I don’t know who to trust More Strain • I withdraw and keep my head down hoping this will all go away 17 A Leader’s Fear Fear • How do I help others make progress? • How do I help others face new realities? • How can I deal with growing expectations? Anger, suspicion and withdrawal • Everyone feels entitled to have everything their way • Nobody understands what I do • I give up on trying to get my colleagues to come to meetings - I’ll just make a decision More Strain • I have too many crises to take the time needed to develop new, creative approaches 18 A Patient’s Fear Fear • Something is wrong with me and I will not get the time and attention I need. • This system is so fragmented the doctors are not communicating with each other. • I can’t pay for what I need. Who is my advocate? Anger, suspicion and withdrawal • I’m on my own. I want all the tests my insurance will pay for. • • The real answer is being withheld from me. I don’t know who to trust More Strain • I don’t even enter the system because I don’t know how to find what I need 19 The Failing Heart of Health Care Strain of change Suspicion Anger Withdrawal Reflexes make things worse Fear 20 Our Reflexes Thwart Us • Reflex response is exaggerated by the pace, volume, chronicity and constancy of change 21 What is hard now about being a nurse/clinician/staff in an integrated system? • I feel like I have no voice • There are things being asked of me that I don’t know how to do and I’m not sure if I want to do them! • I am tired – how can I really impact better care for patients? • I am working as fast as I can and it is never enough – who has time to lead? • Other fears? 22 Reflex Response to Fear Previous Fear means I feel at risk Something is wrong I need to escape I am going to protect what is mine Opportunity Fear is a signal in response to the strain of change Acknowledge losses Engage together in creating new reality 23 “People who thrive in difficult times do two things... face reality and remain hopeful.” -Victor Frankl Face Reality AND Remain Hopeful Face Reality Corrosive Cynicism AND Remain Hopeful Face Reality AND Remain Hopeful Irrelevant Idealism Why Adaptive Leadership? • Describes what people do • Describes what people exercising leadership can do if they see differently • A way of developing a shared language to describe group dynamics • Describes a way to be an active engaged organizational citizen • Really resonates with clinicians 27 Adaptive Leadership Work of Ron Heifetz, M.D. • People adapt more successfully to their environments by facing painful circumstances (aka FEAR) and developing new attitudes and behaviors. 28 Opportunities • Enhance capacity to exercise leadership • Build a framework to help others make progress on tough problems • Create resiliency to withstand the work of leadership 29 Five Big Ideas • Productive range of tension • Difference between technical and adaptive work • Difference between role of authority and the exercise of leadership • Reflecting in action • Work avoidance as a signal of being outside the productive zone 30 Big Idea #1 There is a productive range of tension needed to make progress on adaptive work. 31 Human Systems Tension of change Limit of tolerance Productive Range Threshold of learning Time Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108. 32 33 Human Systems I don’t want to hear any more bad news. I can’t make sense of any of this. I am so terrified I don’t understand a word you are saying. Limit of tolerance I understand the reality of my condition. I am looking to you for guidance and honesty. I understand what I need to do. Productive Range Threshold of learning I came for a pill Time Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 34 Human Systems Limit of tolerance Productive Range Threshold of learning Time Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 35 Big Idea #2 There are two types of problems… Technical and Adaptive 36 Type of Situations Requiring Leadership Technical - Apply abilities that already exist in the system’s capabilities Adaptive - People deeply and broadly within the organization need to learn new capabilities 37 Technical vs. Adaptive Work Adaptive Challenge Tension of change Limit of tolerance Productive Range Holding Environment Threshold of learning Technical Challenge Time R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg. 108. 38 What is hard about leading others in improving care? 39 Properties of Adaptive Challenges Wicked Problems • Gap between way things are and desired state • Varied points of view • Requires difficult learning • Involves facing loss • New competencies must be developed • People with problems have problem solving responsibility • Takes longer than technical work • Requires trying things • Generates disequilibrium, distress and work avoidance 40 The most common cause of leadership failure is treating an adaptive problem with a technical fix. 41 Adaptive Work Adaptive work diminishes the gap between the way things are and the way things need to be to create a better future Adaptive leadership is the activity that mobilizes people to perform needed adaptive work 42 43 Big Idea #3 There is a difference between the role of authority and the exercise of leadership. 44 Authority Leadership • Leadership is an activity • Authority, power and influence are tools but do not guarantee leadership - necessary but insufficient 45 Authority is a Resource to Leadership • Authority provides • Direction • clarify roles and offer a vision • Protection • make sure that group is not vulnerable and can survive external threat • Order • maintain stability 46 Formal and Informal Authority • Big title or big influence • Same social contract • Power entrusted in exchange for fulfilling expectations • An authorizer is anyone who gives you attention and support (power) to do the work of providing solutions to problems 47 Exercising adaptive leadership is different • Different – from authoritative expertise – from holding high position in organizational structure Many people occupy positions of senior authority without ever leading their organizations through difficult but needed adaptive change 48 Exercising adaptive leadership is different – than having enormous credibility, trust, respect, admiration and moral authority Those with a large group of admiring followers frequently protect their informal authority and fail to mobilize their followers. They may collude with their constituents by: - minimizing the losses the followers will need to live with - pointing at “others” who must do the changing - denying or delaying in facing what needs to change. 49 Authority (whether formal or informal) is necessary but insufficient for the exercise of leadership. Ability to constructively influence is a for leadership critical resource even when/if you have a big title. 50 Develop your ability to influence others. 51 Developing Influence • Assess their capability • Help them see what’s in it for them • Earn trust • Speak to their perception of cost • Acknowledge their perception of risk Adapted from C. Dwyer, The Shifting Sources of Power and Influence, Amer Coll of Phys Executives, 1992 52 Your Success at Influencing Another • Their capability to do what you ask • Plus + • (Their Perception of Potential Benefit X Their Perception of the Probability of the Benefit Really Happening) • Minus • (Their Perception of Cost -Their Perception of Risk) It’s all about perception. 53 Developing Influence Perception Matters • How you will tend to see issue • How other will tend to see issue – Over focus on • Potential gain to other – Over focus on • Potential risk • Potential cost • Extent to which you are trusted Adapted from The Shifting Sources of power and Influence – Dr. Charles E. Dwyer 54 Formal and Informal Authority • Power Increases when expectations are met Decreases if expectations are not met People look to you to serve a set of goals they hold dear 55 Resistance (passive or active) • a signal that you are losing influence and are exceeding the amount of loss and uncertainty they can tolerate. • means you must clarify your intentions, refine your approach to the tensions between perspectives (conflicts) inherent in the issue and try again to help the group make progress. 56 57 Speak to their perception of cost • Costs are real – time, energy, opportunity – What are they giving up? • It is their perception that matters – Tendency to exaggerate Having options and regaining some control can help 58 Acknowledge their perception of risk • Change = Unknown = Fear • Can you see their point of view? – Do they think they are getting in over their heads? – Do they think they are writing you a blank check? – Do they think they will be punished by their associates? – Do they think they will always be called upon to make a sacrifice/take on a distasteful task? They WILL NOT and perhaps CANNOT tell you exactly what loss they fear 59 Emotional Bank Account Esteem Acceptance Respect Adapted from S. Covey Sr., Seven Habits of Highly Effective People, Simon and Schuster, 1999 60 Emotional Bank Account Balance Sheet • Courtesy • Kindness Esteem Acceptance • Honesty • Keep commitments Respect • Discourtesy • Disrespect • Interrupting • Overreacting • Causing another to feel ignored • Becoming arbitrary • Betraying trust • Threatening Adapted from S. Covey Sr., Seven Habits of Highly Effective People, Simon and Schuster, 1999 61 Build Up The Emotional Bank Account • Understand the individual – • seek to understand the way you want to be understood Attend to the little things – be kind and courteous • Keep commitments • Clarify expectations • Personal integrity – Walk your talk – Be loyal to those not present • Sincerely apologize when you make a “withdrawal” Adapted from S. Covey Sr., Seven Habits of Highly Effective People, Simon and Schuster, 1999 62 Constraints of Authority People will trust you when you fulfill their expectations (their wants and needs). Your balance increases in their emotional bank account People will distrust you when you fail to fulfill their expectations (their wants and needs). Your balance decreases in their emotional bank account 63 Exercising leadership to do adaptive work means disappointing people’s expectations at a rate they can tolerate. 64 Exercising leadership to do adaptive work means disappointing people’s expectations (that things will stay the same) at a rate they can tolerate. ( and not ignore you or try to silence you or resist in infinitely creative ways ) 65 Big Idea #4 Reflect in Action Get on the Balcony 66 Reflect in Action Balcony AND Dance Floor • Keep the pattern of the dance in mind • Dance • Move back and forth 67 68 Over focus on the Balcony 69 Over focus on the Dance Floor 70 Progress on Adaptive Work GAP + See patterns Get insights Reevaluate assumptions See new connections Balcony _ Engaged Build credibility Understand the work and what it is asking of people Feel what others feel AND Disengaged Checked out Not relevant Make others feel manipulated + Dance Floor Can’t see big picture Forget what the work is Exhaust self with busyness _ Problem keeps recurring 71 Big Idea #5 Work Avoidance as a Signal of Being Outside the Productive Range of Tension 72 Making Progress on Work Tension of change Adaptive Challenge Limit of tolerance Productive Range Threshold of learning Technical challenge Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 73 Making Progress on Work Tension of change Adaptive Challenge Limit of tolerance Productive Range Threshold of learning Technical challenge Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 74 The Work Distress Tension of change Limit of tolerance Productive Range Threshold of learning Distress Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 75 The Work What People Will Not Tell You, Their Behavior Will Reveal Blame others, distract attention, denial Distress Tension of change Limit of tolerance Productive Range Threshold of learning Blame others, distract attention, denial Distress Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 76 Work Avoidance (Resistance) • • Displacing responsibility • Attack authority • Kill the messenger • Scapegoat Distracting attention • Pretend to be busy • Define problem to fit your competence • Make the problem too big • Restructure/reorganize • • • Meetings with only information exchange when engagement is needed Pick a fight Denial 77 Group Discussion: What kinds of work avoidance have you seen in others? What kinds of work avoidance have you seen in yourself? 78 Work avoidance signals being out of a productive zone relative to the work Adaptive Challenge Limit of tolerance Tension of change Work avoidance PRODUCTIVE RANGE HOLDING ENVIRONMENT Work avoidance Threshold of learning Technical challenge Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 79 Resistance (passive or active) • a signal that you are losing influence and are exceeding the amount of loss and uncertainty they can tolerate. • means you must clarify your intentions, refine your approach to the tensions between perspectives (conflicts) inherent in the issue and try again to help the group make progress. 80 Five Big Ideas • Productive range of tension • Difference between technical and adaptive work • Difference between role of authority and the exercise of leadership • Reflecting in action • Work avoidance as a signal of being outside the productive zone 81 Exercising Leadership Four Fundamentals Questions • What is the work? • Who cares about the work? • How are the people who care about the work reacting to the work? • What do I do next? 82 What is the work? Gap = difference between the way things are and the desired state Where do we begin? Meaningful and Manageable 83 WHY An important part of your job is to keep assuring there is a shared understanding of the purpose of the work AIM Statement • The work you are doing together – Addresses a gap – A big enough improvement target to be meaningful – A contained enough project to be manageable • Has key components – Clearly articulated statement of intended improvement – Aligned to strategic focus – Supports system quality or operations goals 85 Properties of Adaptive Challenges Wicked Problems • Gap between way things are and desired state • Varied points of view • Requires difficult learning • Involves facing loss • New competencies must be developed • People with problems have problem solving responsibility • Takes longer than technical work • Requires trying things • Generates disequilibrium, distress and work avoidance 86 Who cares about the work? Important stakeholders – Team members – Those affected by the change • Those who support it • Those who do not want to see it happen – Project sponsor – You – Who else? 87 Who Cares About the Work? Adaptive Work You 88 The Work You Are Approaching Tension of change Limit of tolerance Productive Range Threshold of learning Time Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108. 89 Your Work Distress Tension of change Limit of tolerance Productive Range Threshold of learning Distress Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 90 How are the people who care about the work reacting to it? Interpret Factional Stances: • Is the faction above the limit of tolerance? Over the top • Is the faction engaged in the work? • Is the faction below the level of learning? Not my problem 91 Are you reading the signals others are sending? Work avoidance is triggered when the heat is too high or too low Adaptive Challenge Limit of tolerance Tension of change Work avoidance PRODUCTIVE RANGE HOLDING ENVIRONMENT Work avoidance Threshold of learning Technical challenge Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 92 How are you and others reacting to the work? What does the work avoidance suggest? Adaptive Work You 93 Begin to Plot A Strategy Develop and Execute a Plan • What do you need to do to make progress? • What can you do to lower the distress on the factions above the limit of tolerance • How can you maintain engagement of factions that are currently engaged in trying to make progress? • What can you do to raise the distress to a productive level for the factions below the level of learning? 94 What do I do next? • Use yourself differently • Keep people who are making progress engaged and figure out what you need to do to reengage others. 95 Use Yourself Differently • Set a great example • Celebrate and learn from what is going well • Talk about why you think this is important • Ask questions • Listen • Pay attention • Be thoughtful about where you spend your time – Where is your most productive place 96 Dialogue “Dialogue is a particular style of conversation the objective of which is to increase the overall intelligence and wisdom of the group. It is characterized by honesty (both intellectual and emotional), curiosity, reflection, and a willingness to learn in public.” 97 Duncan Holloman “The single biggest problem with communication is the illusion that it has taken place.” George Bernard Shaw 98 99 Why Practice Dialogue? • Increase the intelligence of the group • Build and maintain trust • Support sustainable and sustaining relationships • Work together more effectively • Address adaptive challenges- those for which there is no technical fix 100 Key Practices • Show up • Listen with curiosity • Notice and suspend judgments and assumptions • Speak your truth with intellectual honesty and emotional conviction • Practice awareness • Commit to the collective learning • Use your authority as a resource to group to invite and protect practice of dialogue 101 Behaviors That Build Trust • Talk straight • Demonstrate respect • Create transparency • Right wrongs • Show loyalty • Deliver results • Get better • Confront reality • Clarify expectations • Practice accountability • Listen first • Keep commitments • Extend trust Adapted from The Speed of Trust, Stephen M.R. Covey, 2006. 102 What do I do next? • Use yourself differently • Keep people who are making progress engaged and figure out what you need to do to reengage others. 103 Work avoidance signals being out of a productive zone relative to the work Adaptive Challenge Limit of tolerance Tension of change Work avoidance PRODUCTIVE RANGE HOLDING ENVIRONMENT Work avoidance Threshold of learning Technical challenge Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 104 Think about a time when the heat was too high. • How did you know? • What did you do to bring things to a productive level of tension so progress could be made? 105 Lowering the Heat • Validate feelings, acknowledge loss • Simplify and clarify • • • Address the technical aspects Break problem into parts Restore, add, or reallocate resources • Temporarily reclaim responsibility for tough issues • Give your attention • Take stock of what is available • Allot more time, enrich knowledge and skills 106 Think about a time when the heat was too low. • How did you know? • What did you do to bring things to a productive level of tension so progress could be made? 107 Raising the Heat • • • • Raise the standards Increase accountability Change the task to something more motivating Refocus on higher, more widely shared and yet compelling purpose 108 Exercising leadership requires keeping an experimental mindset • Work avoidance looks the same when the heat is too high or when the heat is too low. • If what you try makes things worse, try the opposite. • What looks like laziness may be exhaustion. • Keep rechecking your assumptions. 109 Keep an Experimental Mindset When you try something and things get worse, try the opposite! Adaptive Challenge Limit of tolerance Tension of change Work avoidance PRODUCTIVE RANGE HOLDING ENVIRONMENT Work avoidance Threshold of learning Technical challenge Time Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108 . 110 In Health Care Today: When you don’t know what to try first, lower the heat • Validate feelings, acknowledge loss • Simplify and clarify • Restore, add, or reallocate resources 111 Exercising Leadership Four Fundamental Questions • What is the work? • Who cares about the work? • How are the people who care about the work reacting to the work? • What do I do next? 112 Organizations are illusions; they are just groups of relationships - Parker Palmer 113 One more thing….. You! Resilience Exercising Leadership is Risky Exercising Leadership is Risky • size of change amount of new learning required amount of resistance degree of danger for person exercising leadership Adaptive Challenges are Disturbing Time urgency No clear path Stakes are very high Losses are a given Authority feels the pressure to know What do you need to do when the going get difficult? • Know yourself • Be curious about what you don’t know • Regard personal attacks as commentary on issues, not on you • Sustain relationships you need with allies and confidantes “The cleanest way for a system to bring you down is to let you bring yourself down.” R. Heifetz Your Work How are you doing? Limit of tolerance Productive range Time Threshold of learning Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108. Know Thyself A wind chime comes alive in the wind What is resonating for you? EQ Relationship with authority Personality Empathy Awareness Boundaries Differentiation Degree of detachment Formal roles Informal roles Self concept Family history Loyalties Social roles Preferences (MB type) Defenses Emotional Triggers • Happen fast and have consequences - 10 to 15 seconds to stop the trigger - 5 to 6 hours to recover • Impairs thinking capacity: - Optimally can use up to 8-12 pieces of information - When fully emotionally triggered we can only use 1 Creating a Pause “Freedom is the ability to pause between stimulus and response and in the pause to choose.” Rollo May Be curious about what you don’t know Mine Other’s Intention My intention Intention of other Impact My impact Other’s impact on me Harvard Negotiation Project Mine Other’s Intention X Impact X Harvard Negotiation Project Mine Intention x Impact Good intentions do not make bad impact unimportant or irrelevant Other’s Our assumptions about intentions are often wrong x Harvard Negotiation Project What they think they heard is much more important than what you are sure you said. It Is Not Personal People attack when you represent a message they do not like You are disappointing their expectations at a rate they can’t tolerate When you take attacks personally you: Conspire Collude to take yourself out of the action with the attackers by perpetuating work avoidance What You Do Next Matters Place the focus back on the message and the issues - reframe Your management of an attack (not substance of the accusation) determines your future effectiveness – ask a question Use your allies and confidantes to help you understand what you have come to represent to others Don’t go it alone. Partnerships • Help you get on the balcony • Allies – – Share some part of the professional experience but has a competing interest – care about issue • Confidantes – – no competing interest – care about you Feel physically and psychologically safe Reflect and capture lessons Regain courage and perspective Reaffirm a deeper sense of self and purpose Restore spiritual resources Today • • • 136 Five big ideas – Productive range of tension – Difference between technical and adaptive work – Developing constructive influence – Reflecting in action – Work avoidance as a signal Four questions – What is the work? – Who cares about the work? – How are the people who care about the work reacting to it? – What do I do next? Your resilience – Know yourself – Be curious about what you can’t know – Do not take it personally – it is not personal even though it feels that way – Allies and confidantes – Sanctuary regularly