12 Ways to be a Better Leader.

THE PAGE OF CHANGE is exponential--the quantitative amount of change that we have witnessed in health care over the last nine years will occur again in the next three, and then again in the square root of that number. Imagine how wireless communications has evolved over the past few years or the frustration of purchasing a new computer, knowing that it is outdated by the time you take it out of the box. Analogous changes are transpiring in health care and will accelerate in the wake of mapping the human genome, developing nanotechnology, and applying the sciences of proteomics and robotics to prevent and cure human diseases.

Leadership is about the future. The CEO's primary responsibilities are to author, communicate, and promote the organizational vision and prioritize organizational values to establish creative tension and avoid the presence of oscillating structures within the organization. [1] The vision provides inspiration and direction and gives context to daily work. Creative tension is the awareness of the gap that exists between current reality and the idealized future articulated in the vision.

At times of transformational change, failure to lead fatally compromises organizational adaptability and sustainability. However, because challenging the status quo generates resistance and anxiety, successful leaders walk a tightrope between serving as lightning rods for change and adaptability and creating organizational turmoil. For that reason, courage is perhaps the single greatest attribute of transformational leadership. However, too frequently micromanagement passes for leadership, and plans and programs pass for vision.

Fostering adaptability

What follows are a dozen points to help physician executives foster adaptability and sustain the organization's purpose/mission.

1. Celebrate the workforce. Reaffirm/acknowledge the workforce at every opportunity. This psychic income is critical to maintaining strong morale and retaining your employees.

2. Remove barriers. Archaic organizational structures and policies complicate relationships and interfere with timely performance. These barriers are self-imposed, easily recognized by the workforce as unnecessary, and amenable to self-correction. Ask your key employees to make a list of things you should stop doing and then stop doing them. It is always easier to remove a known negative than to introduce an unfamiliar positive. [2]

3. Allow people to take risks. Dee Hock has said that given the right circumstances, from no more than dreams, determination, and the liberty to try, ordinary people consistently do extraordinary things. [3] To lead is to create those circumstances. Unless people are free to risk, they will continue to behave in the same way, and you will get the same results. For this reason it is important to pilot new ideas. "It is easier to act yourself into new ways of thinking than to think yourself into new ways of acting." [4]

The rapid cycle improvement methodology, promoted by the Institute for Healthcare Improvement, is a useful model for piloting new ideas that can potentially transform how work is done. You identify and continually assess: (1) a global measure that evaluates the integrated larger goal to be achieved and (2) a measure of a component process that is short-term, easy to collect, and can be used to analyze the results of the focused intervention. An improvement initiative is acted upon and the short-term impact of that change is assessed to guide refinements. In this way you act, measure the impact, interpret the results, and continue to move forward, creating "on the fly." It is an action-oriented approach to making and assessing change. The global measure is essential to insure that any component change doesn't result in a sub-optimization of the more encompassing goal.

4. Stop managing other people's problems. Be a sorter and not a savior! [2] Make time for the important and non-urgent. [5] Be clear in establishing boundaries and defining the minimum specifications that are required for acceptable performance. Establish the appropriate measurement, give those responsible for the work access to real-time feedback, align your incentives, remove barriers, and enforce accountabilities. You get what you accept. When you accept less than you want, you establish a new standard. [2]

5. Prioritize organizational values. If you don't prioritize values--in other words, where you allocate resources--you'll create oscillating structures that result in "flavor of the month" programs and preclude organizational adaptability. [1] For example, if you believe it is important to change how the organization works and embark on a work redesign initiative, you will create pushback within the workforce and begin to see some dissatisfaction and turmoil. If having contented employees is also an organizational value, you place these competing values at odds with each other. Failure to prioritize will cause you to back off the redesign initiative in deference to the employee contentment value. Then, when contentment is reestablished, you begin to feel tension over failing to redesign the work and you oscillate back and forth. Unless you establish which value takes priority, you never move toward completion, hence the "flavor of the month."

6. Stop managing for consensus. In today's environment, leaders are de facto change agents. When you articulate for change, you challenge the status quo. The majority of any group will, of necessity, resist change. If you wait for affirmation and lead to the majority view, you will only tinker around the edges and will fail to position your organization for success. [6]

7. Segment your marketplace. No industry can simultaneously be all things to all people. Different market segments have different needs, expectations, and demographics. Why do we create a single delivery model and presume that it can efficiently and effectively deliver health care to all segments? Mass customization, or even separate operating divisions, is essential to success.

8. Understand who the competition really is. It isn't the nearest full-service health care facility. Rather it is that niche provider(s) that can steal a meaningful percentage of your highest margin service line. Since health care organizations tend to aggregate all their service lines and roll them up into a single bottom line, profitable service lines subsidize less profitable or non-profitable ones. All compete for the same resource pool. Your organization is most vulnerable at that point where you generate your sustaining margin(s). [7]

9. Establish new relationships. Because the future is unknowable and capital resources are progressively shrinking, organizations can't possibly position themselves for unseen eventualities. There aren't enough resources to build, buy, or borrow all that might be necessary. Hence, the need to seek alliances with others that can complement your core competencies and provide the necessary resources to sustain your organizational mission. [8]

10. Forget about employee satisfaction. Employees are never satisfied. Focus instead on nurturing employee pride, which significantly contributes to retention. Intangible reinforcements like acknowledgement, praise, respect, inclusion, and the opportunity to constantly discover meaning and purpose in work are examples. [9]

11. Stop budgeting departmentally. Patients experience health care horizontally. We insist on dividing our organizations vertically. Is there any wonder why we can't integrate workflows? A corollary here is to stop overemphasizing measures of productivity. This is the single greatest barrier to creativity in organizations. It also serves to reinforce the segmentation rather than integration of work. [10] It is as if we would reward orchestral musicians based on how often or loud they played, rather than on the integrated quality of the music created.

12. Beware of sacred cows. Are you continuing to invest in today's revenue sources at the risk of failing to invest in tomorrow's sources? Understand the natural cycle of clinical process innovation--from emergence to growth to maturity to a critical crossroad often followed by decline--as disruptive technologies shift the historical paradigm. When you find volumes and revenue increasing, but margins decreasing you have defined a failed business model. (Worse yet are those organizations that are experiencing falling volumes and revenue.) Failure to redesign the model threatens the sustainability of the organizational mission.

Conclusion

Micromanagement can no longer pass for leadership. Plans and programs can no longer substitute for vision. Human capital is more important than financial capital, and the risks and rewards of leadership in health care are greater than ever before. An entrepreneurial attitude, an emphasis on people management, and the ability to lead and manage change are the prerequisites for success in today's turbulent health care environment. [11]

Joseph S. Bujak, MD, is Vice President of Medical Affairs at Kootenai Medical Center in Coeur d'Alene, Idaho, and an affiliate of Kaiser Consulting Network.

References

(1.) Fritz, R. The Path of Least Resistance for Managers: Designing Organizations to Succeed San Francisco: Barrett-Koehler Publishers, 1999.

(2.) Belasco, J. Flight of the Buffalo. New York: Warner Books, 1993.

(3.) Waldrop, M. The Trillion-Dollar vision of Dee Hock. Fast Company. October/November, 1996: 2-10.

(4.) Kofman, F., Senge, P. communities of commitment: The Heart of Learning Organizations. Organizational Dynamics, 1993, 22:5.

(5.) Covey, S. et al. First Things First: To Live, to Love, to Learn, to Leave a Legacy. New York: Simon and Schuster, 1994.

(6.) Bujak, J.S. Culture in chaos: The Need for Leadership and Followership in Medicine. The Physician Executive. 1999 May/June;25(3): 17-24.

(7.) Christensen, C. The Innovator's Dilemma. Boston: Harvard Business School Press, 1997.

(8.) Evans, P., Wurster, T.S. Blown to Bits: How the New Economics of information Transforms Strategy. Boston: Harvard Business School Press, 2000.

(9.) Atchison, TA. The Myths of Employee Satisfaction. Healthcare Executive. 1999 March/April; 14(2): 18-23.

(10.) Pfeffer, J. The Human Equation: Building Profits by Putting People First. Boston: Harvard Business school Press, 1998.

(11.) O'Connor, E., Bujak, J. Looking for Answers in New Places: Applying Lessons from Winning Organizations. The Physician Executive. 2000 September/October; 26(5): 56-63.

KEY CONCEPTS

* Transformational Leadership

* Entrepreneurial Attitude

* People Management

* Managing Change

* Enhancing Organizational Adaptability

What are the prerequisites for leading successfully in today's turbulent health care environment? An entrepreneurial attitude, an emphasis an people management, and the ability to lead and manage change. This article offers a dozen suggestions for fostering adaptability and helping sustain the organization's purpose/mission: (1) Celebrate the workforce; (2) remove barriers; (3) allow people to take risks; (4) stop managing other people's problems; (5) prioritize organizational values; (6) stop managing for consensus; (7) segment your marketplace; (8) understand who the competition really is; (9) establish new relationships; (10) forget about employee satisfaction; (11) stop budgeting departmentally; and (12) beware of sacred cows. Courage is perhaps the single greatest attribute of transformational leadership.

Beginning on Monday Morning...

1. Celebrate the workforce: Start every meeting with a story about how someone in the organization has made a difference.

2. Remove barriers: Flow chart your key processes, identify at least one redundant or unnecessary step, and remove or bypass it. For example, raise the dollar limit for departmental spending authority and remove the need for hierarchical approval. Simplify!

3. Allow people to take risks: Experiment with ideas on how to reduce total waiting time for segments of your emergency room patient population. Gather ideas on how to streamline components of the process, like registration, triage, lab turnaround time, and act upon them. Consider cross-training individuals to combine functions. There are a thousand good ideas in your organization. Allow someone with passion for the outcome to pilot the idea. Assign the appropriate measurement, and then create on the fly.

4. Stop managing other people's problems: Clarify expectations, define the appropriate measurement(s), and then hold people accountable for performance. For example, employee retention is primarily dependent on the relationship with the supervisor. Make supervisors responsible for sustaining employee pride, measure employee attitudes and turnover rates, and evaluate and reward supervisors according to their measured performance.

5. Prioritize organizational values: Preferably list three or fewer. The dominant value defines the essence of the organization and guides decision-making. One example might be that you choose to value above everything else that all health care decisions are based on patient beliefs, values, and choices rather than the preferences of the caregivers. Such a value makes clear how choices are to be made. Think of Nordstrom's commitment to always first serve the customer.

6. Stop managing for consensus: Think slinky! Create change by addressing those who are ready for it--allow them to design the new behaviors, document their value, and recognize that others will copy their success. Use this pull strategy, rather than trying to push everyone ahead from behind. For example, if you want to apply a care path or evidence-based medical guideline, identify physicians who are willing to proceed and begin. Measure the outcome of the intervention and allow its success to promote others to choose to participate.

7. Segment your marketplace: An example is integrating the health care needs of women in shopping malls where all necessary services are available on the same day with short turn-around times. The patients (customers) can shop, get a massage or manicure, or have lunch and are paged when results are in or their next diagnostic step is ready.

8. Understand who the competition really is: Surgeon-owned ambulatory surgery centers, gastroenterologist-owned endoscopy suites, and urgent care centers are examples of niche businesses that are eroding some of your most profitable service lines. Responding to this challenge is more critical than "going to war" against the health system across town. In partnering for the future, think "both-and," and not "either-or."

9. Establish new relationships: Partner with GE to develop imaging services or with a pharmaceutical firm to begin a diabetes management center. Outsourcing creates a win/win with partners whose core expertise can enhance the overall patient experience.

10. Forget about employee satisfaction: Teach, coach, and model how to praise employees. Make supervisors responsible for creating opportunities for their direct reports to frequently experience meaning and purpose in their work. Measure their performance and reward them appropriately.

11. Stop budgeting departmentally: Action-based accounting represents one approach to allocating indirect costs in proportion to how much they are actually used by an integrated service line. Create actual or virtual separate operating companies in order to allow for a sharper focus and an opportunity to create new models of service delivery in an environment that doesn't force them to compete with other service lines for organizational resources. Begin one product line at a time. Organizing work horizontally, in a way that reflects how the patient experiences care, creates a more meaningful approach to organizational design.

12. Beware of sacred cows: Traditional therapeutic and diagnostic approaches to cardiovascular disease and cancer are being challenged. Total deference to the dominant models of today may compromise your organizational sustainability. Programs in complementary and alternative medicine, nutritional therapy for coronary artery disease, and integrated programs in occupational medicine are examples of emergent business models. In today's fast-paced world it is more important to be right than not to be wrong.