Carrying the load together.

The demands for improved patient safety, a new information system, better physician-administrator relations, and constrained costs continue to haunt Dr. Bartz.

As the new CEO of the city's largest community hospital, she knows it is time for change. While the former CEO continued to bury his head in strategies that had served him well for two decades, support for his leadership deteriorated and Bartz was swept into the executive office.

Now it appears the people are looking to her for answers that frankly she just doesn't have. In the past, it has always been the CEO's job to provide those answers and people are now waiting to see what she will do.

As Bartz sits at her desk at the end of another long day she again can't help but wonder where these answers will come from. Clearly the hospital has many capable people on its staff, but how can she get them to come for ward with their ideas and accept responsibility for making them work?

Our prior columns clarified the need for a compelling vision, the importance of aligning systems and structures with that dream, the importance of a supportive culture, the need to minimize resistance, and the importance of leading people through the emotional stages of a transition.

But what steps can you take as a leader to involve your people in getting these important pieces in place? Do you have to do all this yourself, or are there leadership strategies that will encourage your people to step forward and willingly carry this burden with you?

Asking effective questions

Where are you as a leader focusing the people in your organization? Do you have them thinking and talking about who is to blame for the problems you are facing? If instead they are focusing on the positive possibilities of winning together, you are far more likely to gather the ideas and support you need to enhance quality, improve relationships and constrain costs.

But how can you effectively begin to focus your people on winning together and providing you with their valuable ideas? While answers are what we want, questions are the place to start. What types of questions are most useful?

You might ask people what the problem is, who the problem is, or who is to blame. If you do so, people typically learn to focus on defending themselves or their group to ensure that no blame can fall upon them. With this as their focus, limited creative energy will be available to generate innovative solutions to the quality, cost, or access challenges confronting your health care organization.

Experience suggests that more effective questions include asking:

* What is already working?

* What makes it work?

* What is our objective?

* What are the benefits of achieving this objective?

* What can we do to move closer to our objective? (1)

These latter questions focus people forward on future possibilities. Noticing what is already working and what makes it work provides a positive environment in which to examine mutually desirable future objectives, the benefits of achieving them, and the strengths that already exist that can be used to progress toward those future objectives.

How does your leadership look when compared with this list of winning questions? Would they sound familiar to your people?

Sharing responsibility for achieving outcomes

Identifying your path to the future together is an important first step in sharing responsibility for solutions with your people. Further progress depends upon your ability to delegate responsibility by creating alliances that serve as the basis for powerful coalitions of like-minded partners.

Such alliances can be built based upon reaching mutual agreement in four areas:

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1. Results: What is the end point to be achieved as a result of this alliance?

2. Accountability: Who will be responsible? When and how will outcomes be measured?

3. Motivators: What resources will be provided to support the likely success of the venture? What benefits for success or consequences for failure will exist for each of the people/groups willing to assume responsibility?

4. Parameters: What limits regarding methods to be used will be placed on the discretion of those responsible for success? What are the practical and/or ethical boundaries and the remaining areas open to choice? (2)

Let's assume that Bartz, the CEO described in our opening story, wishes to utilize such a RAMP (Results, Accountability, Motivators, Parameters) agreement approach to recruit her colleague Mr. Adams, a respected opinion leader, to assume responsibility for the hospital's current cost containment initiative. The result to be achieved (such as reduced costs) may seem obvious. However, the magnitude of the reductions, combined with the simultaneous improvements in quality measures required to fulfill customer requirements, may not be thoroughly understood.

If Adams is willing to discuss assuming accountability for the initiative, it is important that he and Bartz reach a common, measurable definition of success for the venture. For example, regarding costs, they might agree to consider the project to be successful if the hospital's medical staff approves, by July 1, 200X, a detailed proposal to reduce expenditures by six percent per year starting January 1, 200X+1.

Motivators and parameters should also be specified in this agreement. While relevant motivators can entail money, other currencies can also be exchanged. For example, in this situation Bartz might agree that the satisfactory completion of this task will result in:

* No further requests to Adams to lead major projects for a specified period of time

* His release from current service on the hospital's quality assurance committee

* A public acknowledgment by Bartz of her respect for the success of another venture Adams recently led

Parameter agreements might involve providing only four hours of clerical support time per week to Adams throughout the duration of this project, and the understanding that Adams will not communicate his final proposed plan to others until it has been presented to and discussed by the hospital's board.

If agreements can be reached regarding these parameters, Bartz can use the time saved through the formation of this partnership with Adams for other pressing issues.

Providing choice while negotiating the four Results, Accountability, Motivator, and Parameter dimensions may seem overly complex. The time pressures you are under and your desire to have it done your way may seduce you into trying to tell people what is required of them.

Unfortunately, negative consequences regularly occur when we demand that our opinions be accepted by independent professionals. They may simply choose not to comply. Or perhaps they will go through the motions. However, as long as they believe they are simply helping the leader, Bartz, with her problem versus fully accepting responsibility for its successful solution, the department cannot be guaranteed that it will receive their best efforts.

Negotiating versus assigning responsibilities or getting people to grudgingly accept them out of guilt encourages the active involvement of others in carrying your load together. How does your leadership look when compared with this list of winning practices? Would they look familiar to your people?

Edward J. O'Connor, PhD, is principal with the Implementation Institute, a professor of management and health administration at the University of Colorado at Denver and Health Sciences Center and a member of the faculty of the American College of Physician Executives. He can be reached by calling 303-573-1273 or by e-mail at [e-mail].

C. Marlene Fiol, PhD, is a professor of strategy and health administration at the University of Colorado at Denver and Health Sciences Center. She can be reached by phone at 303-556-5812 or by e-mail at [e-mail].

References

1. Oakley E. and Krug D. Enlightened Leadership. Simon & Schuster, New York, 1994.

2. O'Connor EJ and Fiol, CM. "Leading the way." The Physician Executive, November-December, 1997.

By Edward J. O'Connor, PhD, and C. Marlena Fiol, PhD

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