Culture in chaos: the need for leadership and followership in medicine. (Competing On the Edge).

KEY CONCEPTS

* Physician Culture

* Physician Resistance to Change

* Leading for Change

* Health Care as a Complex Adaptive System (CAS)

* Complexity Science and Nonlinearity

The health care industry is changing at a dizzying pace and most of its players are struggling to maintain some form of the status quo. But resisting change will not prove fruitful--ultimately, it will rob physician executives of the opportunity to be architects in designing a new, more efficient health care system and their role in it. Because health care is a complex adaptive system (CAS)--change occurs rapidly and events are unpredictable--the old command and control style of leadership and a linear way of interpreting events is too rigid and, therefore, an ineffective model for guiding change. Complexity science offers insights about leading for change. In CASs, changes emerge in response to environmental demands for adaptability. Since the nature of these demands is unpredictable, the role of leadership is to manage the relationships and context out of which these changes emerge. A leadership style is called for that leads to purpose, makes positive changes by influencing context and relationships, and t akes followers to a better place.

PHYSICIAN CULTURE IS dissolving. Our roles, relationships, values, assumptions, and behaviors are being challenged by other competing and legitimate views. Professional satisfaction appears to be at an all time low. There is growing talk of unionization and several physician groups have already chosen this option as a defense against progressive loss of control. There is very little joy visible in the health care professions. Meetings are dominated by discussions about governance, personal economics, and strategies to resist change. New relationships are forged in an atmosphere of distrust. Almost all of these new relationships are rooted in zero-sum games of economic self-Interest. Many of the initiatives intended to integrate the provider community are now disintegrating.

Aggregation is occurring everywhere. The cottage industry of medicine has become corporatized. Most physicians now work in some form of employed status. The amount of information available overwhelms the unaided human mind. The implications for a profession that so jealousy covets personal autonomy are overwhelming. The rapidly transforming health care landscape is presenting unprecedented challenges. Never before has there been such a need for leadership and followership in medicine.

Once predictable, now chaotic

Competition, consumerism, and advancing technology are three major forces that are quickly transforming health care. (1) Each of these forces challenges traditional physician roles, relationships, beliefs, values. and behaviors. What was once comfortably predictable is now chaotic. The need for rapid change challenges physicians to define what is immutable about their role in society as opposed to those behaviors, attitudes, and beliefs that represent historical artifact. Too many of us have come to see ourselves in terms of what we do and how we do it. If you are what you do, and you don't, then you are not! Who and why have been lost in what and how.

Organizations are restructuring and redesigning work processes in response to the challenges of a competitive global economy. The explosion of information and the quick and universal access to it is changing the nature of competition in the marketplace. Consumerism dominates almost every industry, and is beginning to transform health care delivery. Attempts to successfully respond to these challenges in other industries have led to an appreciation for the value of teamwork, decentralized decision-making, flattened organizational hierarchies, knowledge capital, disintermediation, and operational transparency. (2)

All of these trends stand in dramatic contrast to the operational paradigm of physicians. Despite the demonstrated superiority of these approaches, physicians desperately cling to the metaphor of the all-knowing ship's captain, commanding and controlling situations. Even airline cockpits and the U.S. Army's National Training Center have forsaken such a model. (3)

Cultural barriers

Given these challenges, why is there such a paucity of visible physician leaders? Where are the spokespersons for the profession? I believe that physicians are victims of their own enculturation. We are self-selected for and trained to value competitiveness and autonomy. Both of these attributes interfere with our ability to lead and to follow, and to negotiate new roles and relationships. Competitiveness breeds distrust, In the process of creating new relationships, competitive persons negotiate for win/lose. Lacking in trust, when winning isn't possible, compromise or lose/lose is preferable to collaboration or win/win. Trust is essential for collaboration. (4)

A desire for autonomy explains other behaviors. Physicians approach negotiation from a "what's in it for me" position. This hinders our ability to fashion relationships of shared purpose. Also, while physicians are quick to voice their opinion, they are reluctant to speak on behalf of their colleagues. I think this is because they would resent others presuming to speak on their behalf. This inhibits the emergence of leadership and, more importantly, almost precludes followership.

Scientific training often hinders physicians' ability to relate to other stakeholders in health care. Scientific reductionism promotes a linear view of cause and effect. Clinical decision-making often reinforces this way of thinking. Lacking a systems perspective, physicians tend to adopt a personalized, anecdotal, and short-term frame of reference. These traits further leave physicians organizationally impaired.

What is leadership?

While it is easy to make a call for leadership, it is more difficult to define what it is. According to O'Toole, leadership is about ideas, transcendent vision, and the need to pursue a moral imperative. (5)

Effective leaders have passion for their vision and a passion to lead. They have compassion for those they would presume to lead and highlight the best in their followers, thereby giving them hope. Their vision encompasses the needs and aspirations of their followers, but will lead them to a place far better than they could have imagined on their own.

Leading to vision is important. Pursuing shared vision is necessary to overcome the pettiness of self-interest. While positive vision is the only force that can sustain effort over time, there is a simultaneous need to create a sense of urgency. This negative vision is essential to mobilize groups-it affects the timeline of change and overcomes the inertia of the status quo. However, since negative vision seeks to reduce the intensity of a perceived or actual threat, actions taken to lessen that threat simultaneously reduce the need to act. This creates a reactive and fragmented response.

Once motivated to action by negative vision, the simultaneous ability to demonstrate the benefits of pursuing the positive vision can create some early benefits and initiate a positive feedback loop. The momentum thus generated can hopefully sustain a commitment to creating the desired future. In this context, Robert Fritz characterizes problem solvers, one form of negative vision, as persons who seek to make things go away. This stands in contrast to creators, those in pursuit of positive vision, who seek to bring something into being. (6) Herein lies a profound

distinction.

Leadership involves evoking behavioral change. Charles Dwyer, PhD, of the Wharton School of Business, pragmatically advises that in order to influence others, they need to perceive that adopting the new behavior will enhance something that they personally value. (7)

Nonlinear, unpredictable, and unmanageable

Complexity science and its focus on nonlinearity gives hope and insight to those who would seek to Influence health care. Health care is a complex adaptive system (CAS). It is complex in that it is comprised of many subsystems or agencies, each of which is interdependent within the larger system. For example, the Health Care Financing Administration, state Medicaid departments, business purchasing coalitions, state and federal legislatures, technology development companies, insurance companies, physician groups, nurses, alternative care providers, and consumer groups are some of the subsystems within health care. Changes that occur in any one of these agencies can profoundly impact others who are part of the larger health care system.

Health care is adaptive in that each of these subsystems operates independently according to their own rules and in response to their local environments. Moreover, they can at any time independently change the rules by which they operate. Therefore, the system is nonlinear, unpredictable, and unmanageable. More importantly, because it is nonlinear, small changes can have very large effects. Positive feedback loops can amplify consequences. Because these systems are interdependent, they in fact co-evolve in response to this constant dialectic of interactions.

Each agency is part of the system. When the agency changes, it alters the environment, which in turn evokes further change in the agency. Any subsystem cannot see itself as independent from the larger system. Any component that would seek to optimize its own position serves to suboptimize the system as a whole. This is why self-interest ultimately weakens the larger system, and why the kind of unionism that seeks to independently enhance the position of one constituency can act to impair the entire system and ultimately harm all constituents.

Influencing the early adopters

The innovation model provides a valuable construct for explaining how change is adopted. (8) In this model, populations are segmented into several types of members. There is a small group called innovators who are infatuated with novelty and broadly seek to discover new ideas. Their frame of reference is external to their peer group, which largely cannot discern if the innovators are ingenious or crazy or both. For this reason, innovators do not influence the mainstream.

The early adopters are the key to disseminating change. This group is open to new ideas and willing to experiment in search of potential applications. They are distinguished from the innovators by being legitimate members of the larger group and, therefore, able to influence others.

The early majority have a local frame of reference. They distrust ideas imported from outside. They are, however, influenced by observing the early adopters' behavior. Once new ideas are successfully incorporated into local behaviors by the early adopters, they begin to copy them. Once this occurs, you couldn't stop the changes from being adopted even if you wanted to try.

Given this model, as Don Berwick has advised, one can lead for change by exposing early adopters to selected new ideas. Since all truly new ideas are imported, this requires sending early adopters "out of town" for an opportunity to discover innovations. By allowing them to experiment with these innovations and to reinvent them locally to improve the fit and legitimize them, one can create an opportunity for the early majority to observe the changes and judge their adoptability. (9)

If physician leaders can let go of the enculturated notion that they have to manage consensus and can focus on influencing the early adopters, they can marshal resources in ways more likely to have an impact. In this way, small changes can have a disproportionately large impact.

Influencing the shadow organization

Complexity science offers other insights about leading for change. In complex adaptive systems, changes emerge in response to environmental demands for adaptability. Since the nature of these changes is unpredictable, the role of leadership is to manage the relationships and context out of which these changes emerge. To clarify this concept, Gareth Morgan has popularized the metaphorical analogy, "Farmers don't grow crops, they create conditions in which crops grow." (10)

Ralph Stacey writes that organizational creativity and adaptability emerge from the shadow organization at the edge of chaos." Where there is a high level of agreement (where you want to go) and certainty (how you are to get there), you manage for desired intent. In these circumstances, traditional, legitimate organizational structure, tactical goal setting. and managing processes work well. This approach is well suited for enterprises that exist in a stable environment, or where precision and predictability are critical. However, where environmental conditions are rapidly changing, unstable, and unpredictable, this approach is too inflexible.

When agreement and certainty are far from unity, total chaos exists and there is too much fragmentation to allow even common identity. Between chaos and predictability, at the edge of chaos, lies the illegitimate or shadow organization, out of which new and creative adaptations emerge.

Leadership in complex adaptive systems is about controlling the level of organizational anxiety through influencing this shadow organization. (11) This is achieved by balancing the following organizational elements: information, diversity, connectivity, and power. Too little of any favors the status quo. Too much is excessively destabilizing. These principles are what underlie, in part, the management trends of sharing information throughout the organization, promoting learning organizations through dialogue, decentralizing decision-making, and diversifying the workforce.

Margaret Wheatley writes about this style of leadership. (12) She states that for successful organizational evolution to occur, you must allow persons who share a common purpose to engage in "soulful dialogue" after having been given the necessary information about the forces that are impacting them. Out of this, solutions emerge. From this degree of participation and involvement comes a sense of ownership of and commitment to emergent solutions.

Managing paradox

As Gareth Morgan writes, another approach to successful leadership involves appreciating the resistance to change and managing paradox. (13) Significant new ideas challenge the status quo and are resisted by those who benefit from the current system. Each paradigm has merit in its own right. This conflict creates the "yeah....buts" that surface in debates over the value of new approaches. Focusing on how to resolve the "yeah...buts" allows one to discover new ways of advancing change. How can the new ideas incorporate advantages of the old with incremental advantages of the new? This conflict is a source of creativity. Resolving the conflict is one way that creative change can take place.

Morgan further advises that we focus on those areas where we have the potential to assert influence. He postulates that about 15 percent of our total range of activities involve circumstances wherein we have the capacity to be influential. It is in these areas that we should focus our efforts. Because change is nonlinear in complex adaptive systems, small changes can have a disproportionately large impact. Also, small successes within our sphere of influence can serve as prototypes of change for others.

Action-based research is key to creating rapid change in an interdependent and co-evolving complex adaptive system. The Institute for Health Care Improvement (IHI) has utilized this approach with considerable success. In action-based research you define and constantly measure the integrated outcome of the system to be improved. Then, any subsystem within the larger system can be targeted for improvement. A measure of the subsystem's efficiency and/or effectiveness is selected and then, using the "Plan, Do, Check, Act" cycle of performance improvement, selected interventions are tried.

The subsystem measurement guides the improvement process as changes can be modified "on the fly." The integrated system measurement is essential to prevent suboptimization. Sometimes attempts to maximize the performance of a component system can serve to suboptimize the integrated functioning of the whole. Using this approach, IHI has been able to document considerable process improvements in a wide variety of projects, including the therapy of childhood asthma, reducing adverse drug events, and streamlining care in the emergency room. Pascale et al note that we are more likely to act ourselves into new ways of thinking than to think ourselves into new ways of acting. (3)

Followership

What is the nature of resistance to change? James O'Toole provides insight into understanding this phenomenon. All groups are comprised of individuals who share the same assumptions, beliefs, and attitudes. It is this shared ideology that defines them as a group and justifies their behavior. Those who would promote change by challenging these underlying beliefs attack the group where it most vulnerable, at the ideology that defines it in the first place. Those who advocate change are not seen as offering prospects for progress, but rather as giving reproach to the duly constituted social order. (5) Indeed, resistance to change is to be expected and respected. Self-identity, beliefs, and values are being challenged. That is why servant leadership and respect and compassion for followers is critical for successful leadership.

What does it take to accept the leadership of others? The primary requirement is trust. We have seen how competitiveness precludes trust and how autonomy impairs interdependency. How can a group identity be forged? How can individual success be seen as a derivative of collective success? Sports teams share a common purpose, common adversaries, and a good deal of task interdependence and overcome stereotyping to achieve collective success. Prejudice and stereotyping are self-fulfilling prophecies that serve to maintain the status quo. (14) By analogy, creating a shared purpose (vision), defining a common enemy (urgency), and creating an awareness of interdependency are essential objectives for collective success.

The trouble with self-interest

People can be motivated either internally or externally. External motivators diminish the force of internal motivators. Perhaps the economic success of physicians has reduced the influence of initial internal motivators. Most of my colleagues were attracted to medicine out of a desire to care for others. Too often now our behaviors suggest that economic rewards are the primary consideration.

I spend a significant portion of my professional life watching physicians struggle to develop new relationships. Almost all of the dialogue is focused on physician interests with little consideration for the needs of other stakeholders. Governance issues remain rooted in representational structures. All seats must be perfectly balanced, a reflection of the distrust not only toward those outside, but also those within the profession. While there is some concern for inurement Issues, most 50/50 governance structures manifest overriding concerns that no one constituency have an upper hand.

Almost all organizations spend the bulk of their time fashioning documents that address how to distribute reimbursement. Compensation issues consume agendas. Patient care issues almost never surface, and certainly disappear once the marketplace contracts and the organization must evolve to something more than a pass through reflection of business as usual, discounted fee-for-service. Doing the deal is the uppermost consideration. Watching these relationships deteriorate as arguments over money drain the energies of their leadership has convinced me that relationships built on economic self-interest do not endure.

Information destabilizes the status quo. Today, information is available almost instantly from anywhere in the world. The pace and magnitude of change continues to escalate. People used to spend most of the time in between change. Now, most of the time is spent in change. For these reasons, as Joe Flower states, we must find joy in the doing. Surfers don't do all that work just to get to shore." (15) With so unpredictable a future, it is important to be "in the present," to focus on each encounter, and to recognize that today's choices help to create tomorrow's reality.

In seeking to form new relationships, physicians must maintain a primary focus on purpose and principles and not on personal economics. I choose to believe that economic success will be a derivative of a recommitment to service, but it cannot be directly pursued. Society will determine what a physician's services are worth. They are more likely to be accorded a higher value if we are perceived as working on their behalf rather than our own. Even if our services were not more highly valued in economic terms, the ability to help design our future work environment and to gather the rewards of serving others are additional significant reimbursements in their own right. By resisting rather than engaging change, we are foreclosing on our options to serve as contributing architects of our destiny. Continuing to resist ensures that we will become passive recipients of a future created by others.

Conclusion

Only shared and transcendent purpose can overcome petty differences. Viktor Franki eloquently makes the case that responsibleness" is the essence of the human condition. (16) Life is about finding meaning and purpose, about committing to someone or something outside of one's self.

Medicine inherently contains a built-in sense of meaning and purpose. However, too many of us have come to see the means as the ends, to value diagnosing and technological interventions as laudable goals in and of themselves. The individual patient and the context of his or her problem is too often ignored. Attempts to cure often replace healing and caring. (17) Physician self-worth has come to be symbolically measured in economic terms. We have come to engage patients in transactional rather than transformational ways. We have lost focus on the purpose of our work. External motivators have diminished the importance of internal motivators.

Collins and Porras have characterized attributes of enduring organizations. (18) Chief among these is leading to purpose and being values driven. To this end, we in medicine have to rediscover purpose and the essence of our profession. Understanding the marketplace forces that are transforming health care, reowning our history, and accepting the responsibility that we must create our future are required to successfully adapt to our changing environment. We need leaders who can provide direction and manage context and relationships. Those traits that characterize physician culture and impede our ability to adapt need to be altered so that we can begin to trust, act collectively, and recognize that we are a part of a co-evolutionary process, interdependent with others who share health care's complex adaptive system. The answer lies in leading to purpose.

RECOMMENDED READING

This reading list provides primarily non-health care books and articles that further explore the new leadership principles rooted in complexity theory.

Annas, G.J. Beyond the Military and Market Metaphors, The Healthcare Forum Journal, (39:3) May/June, 1996.

Metaphor is the dominant way we acquire insight and new information. Adopting an ecological metaphor would dramatically change our perspective and restructure priorities in decision-making.

Belasco, J.A., and Stayer, R.C. Flight of the Buffalo, New York, New York: Warner Books, 1993.

This exceptional book contains a clearly stated method for empowering the workforce by applying the principles of lean production. Leaders need to become architects of human potential.

Bennis, W., and Biederman, P.W. Organizing Genius: The Secrets of Creative Collaboration, Reading, Massachusetts: Addison-Wesley Publishing Company, Inc., 1997.

This book addresses how to create collaborative advantage by turning individual talent into teamwork. Organizations are too often prisons for the human soul. Could efficiency productivity, and the desire for immediate payoffs occasionally be roadblocks to greatness?

Blanchard, K., and Bowles, S. Gung Ho! Turn On the People in Any Organization, New York, New York: William Morrow and Company, Inc., 1998.

An elegantly simple illustration of the principles of successful management.

Collins, J., and Porras, J. Built To Last: Successful Habits of Visionary Companies, New York, New York: Harper Collins Publishers, 1997.

Commitment to organizational purpose and values is what characterizes organizations that have endured for more than 50 years.

Frankl, V.E. Man's Search for Meaning, revised ed. New York, New York: Pocket Books, 1985.

A must read for physicians who are feeling unhappy or angry over the changes in health care. It helps to reassign priorities and rediscover the true meaning of the physician's role.

Kelly, K. New Rules for the New Economy: 70 Radical Strategies for a Connected World, New York, New York: Viking Penguin, 1998.

This book illustrates how value is created in a networked world. Innovation is more important than efficiency A wealth of information creates a poverty of attention. Since goods and services become more valuable as they become more plentiful, and become cheaper as they become valuable, the most valuable things of all should be those that are ubiquitous and free.

Kofman, F., and Senge, P. Communities of Commitment: The Heart of Learning Organizations. Organizational Dynamics, 1993, 22:5.

Describes how competition, fragmentation, and reactivism interfere with a systems perspective and the ability to identify areas of high leverage.

Maurer, R. Beyond the Wall of Resistance: Unconventional Strategies that Build Support for Change, Austin, Texas: Bard Books, 1996.

This book examines resistance to change and how to deal with it.

Peters, T. The Pursuit of Wow: Every Person's Guide to Topsy- Turvey Times, 1st ed. New York, New York: Vintage Books, 1994.

This is a clear description of how consumerism has become the driving force in the new economy.

Pfeffer, J. The Human Equation: Building Profits by Putting People First, Boston, Massachusetts: Harvard Business School Press, 1998.

The principles of lean production are explored in this book. The seven practices of successful organizations are: (1) employment security (2) selective hiring of new personnel, (3) self managed teams and decentralized decision-making, (4) comparatively high compensation contingent on performance, (5) extensive training, (6) reduced status distinction and barriers, and (7) sharing financial and performance information throughout the organization.

Remen, R.N. Kitchen Table Wisdom, New York, New York: Riverhead Books, 1996.

A powerful book that refocuses the health care professions on wisdom and love. Too often technology replaces humanity as high tech is accorded more importance than high touch. Curing is not the same as healing.

--Joseph S. Bujak, MD, FACP 

References

(1.) Hagland. M. Focused Factories, The Healthcare Forum Journal, 1997, 40(5):22-26.

(2.) Peters, T. The Pursuit of Wow: Every Person's Guide co Topsy-Turvey Times, 1st ed. New York, New York: Vintage Books. 1994,

(3.) Pascale, R, Millemann, M, and Gioja, L. Changing the Way We Change. Harvard Business Review, 1997, 75(6):126-139.

(4.) Shell, R. and Klasko, S.K. Biases Physicians Bring to the Table. The Physician Executive, 1996, 22(12):4-7.

(5.) O'Toole, J. LLeading Change: Overcoming the Ideology of Comfort and the Tyranny of Custom, 1st ed. San Francisco, California: Jossey-Bass Publishers. 1995.

(6.) Fritz. R. The Path of Least Resistance. 1st ed. New York. NY: Nightingale-Conant Corp., 1985.

(7.) Reece, R.L. Changing Perception: An Interview with Charles E. Dwyer. PhD, The Physician Executive, Vol. 25, No. 2, March/April 1999.

(8.) Rogers, E.M. Diffusion of Innovations. 4th ed. New York, New York: Free Press, 1995.

(9.) Berwick, D.M. "Sauerkraut, Sobriety and The Spread of Change," Presentation to the Eighth Annual National Forum on Quality Improvement in Health Care, New Orleans. LA, December 5, 1996.

(10.) Lindberg, C. et al. Life at the Edge of Chaos. The Physician Executive, 1998, 24(1):6-20.

(11.) Stacey, R.D. Complexity and Creativity in Organizations, 1st ed. San Francisco, California: Berrett-Koehler Publishers, 1996.

(12.) Wheatley, M. Leadership and the New Science, Learning About Organizations From An Orderly Universe, 1st ed. San Francisco, California: Berrett-Koehler Publishers, 1994.

(13.) Morgan, G. Images of Organization, 2nd ed. Thousand Oaks, CA: Sage Publications, 1997.

(14.) Goldstein. J. The Unshackled Organization: Facing the Challenge of Unpredictability Through Spontaneous Reorganization. 1st ed. Portland, Oregon: Productivity Press, 1994.

(15.) Flower, J. "Leading Change: A Key Challenge for Board-Management Teams." White Paper #32. The Governance One Hundred of the Governance Institute, 1998.

(16.) Frankl, V.E. Man's Search for Meaning, revised ed. New York, New York: Pocket Books, 1985.

(17.) Goodwin, J.S. Chaos, and the Limits of Modern Medicine, Journal of the American Medical Association, 1997, 278:1399-1400.

(18.) Collins, J, and Porras, J. Built to Last: Successful Habits of Visionary Companies. New York, New York: Harper Collins Publishers, 1997.

(19.) Belasco, James A. Flight of the Buffalo, New York, New York: Warner Books, 1993, p. 306.

RELATED ARTICLE: THE CHANGING NATURE OF LEADERSHIP IN HEALTH CARE

I recently participated in a strategic planning retreat for a health care system. The CEO had announced his intention to retire in the year 2000. The chairman of the organization's board of governors asked me what characteristics should be sought in the ideal replacement candidate. Specifically, he wondered if they should be searching for a physician CEO.

My letter to him attempts to justify seeking a physician replacement and describes the changing nature of leadership in health care. In complex adaptive systems, when change is occurring with ever increasing speed and magnitude, the future is not only unpredictable, it is in fact unknowable. In these circumstances, traditional top down command-and-control leadership is ineffective. (10) Since physicians have been trained to think linearly in the context of scientific reductionism, it is particularly difficult for us to adopt a new style of leadership suited to nonlinear complex adaptive systems.

Letter of reply

"Current wisdom" predicts that within ten years, most health care organizations of any size will have a physician as CEO. The reasons are as follows: (7) If the business of health care is health care, the person at the top should understand the core competencies. (2) It is easier to teach a clinician business principles than to teach a business person about health sciences. (3) From a cost accounting viewpoint, the most critical persons in the health care environment are physicians. They initiate almost all of the significant variable expenditures. (4) Understanding physician culture and relating to that constituency are critical to the future success of the community health enterprise.

More importantly there is a significant choice to be made. Are we going to have a system of cost managed care or one of care managed cost? You can bring an organization to the same endpoint via either approach, but you will end up with two very different organizations.

There are several critical distinctions that should characterize a successful CEO in the information age. First and Foremost, he or she must be a leader as opposed to a manager. Leadership is about inspired followers, management is about predictable results. Leaders must focus on effectiveness and manage for creativity whereas managers focus on today and coordinate efficiencies of operations. Leaders work on paradigms while managers work in paradigms. Leaders give direction, challenge operating assumptions to test their continuing validity seek to recognize patterns that are emerging in their business environment, and position the organization to anticipate and help shape those patterns.

While successful organizations require both competencies, the CEO must provide the leadership function and lead to purpose. Leadership is no longer grand knowing and salesmanship. Rather, it is about influencing relationships and context. It is not having the answers, but being able to frame the right questions. It is about defining the boundaries and the minimum specifications and then trusting that those who actually do the work will discover the correct means to the mutually desired ends. It is about clarifying expectations and defining accountabilities. It is about sharing information and allowing everyone to rediscover meaning and purpose in their work. It is about rediscovering a sense of joy in the workplace.

Being a CEO is about being presidential and about being the keeper of the organizational 'story" It is about being a servant to your followers, respecting and valuing them each individually It is about investing in their knowledge capital, giving them the skills necessary to adapt "on the fly" It is about defining their role in helping to create their future. It is about becoming a sorter and not a savior of those in the work environment. (19) It is about highlighting the best in individuals, thereby giving them hope, and about envisioning a future better than they could have imagined on their own. (5) Lastly the future is progressively more about simultaneously cooperating and competing. The ability to establish networked relationships and the capacity to position the organization for sustainability are necessary competencies.

When persons who share the same purpose are given all the necessary information and allowed to engage in 'soulful" dialogue, solutions to problems emerge. (12) Organizations need to continually reinvent themselves in response to an ever changing and continuously more complex environment. The CEO's job is to nurture this capacity

Success in the information age is more a matter of sustainability, It requires adaptability, flexibility and creativity It is analogous to surfing, a state of almost falling. You have to enjoy the ride. Enjoy and be in the process and, thereby help to create the future, The journey and the destination need to be the same. (15)

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. He can be reached by calling 208/666-2014 or via email at [e-mail].