Six keys to weighing probability and achieving organizational improvements.

Real leadership is the major challenge in improving health care quality and implementing change. Many articles and presentations talk of change without conflict or struggle; however, the rare leader who has successfully achieved a significant improvement will discuss challenges and setbacks.

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While conceptually easy, implementing change is the most difficult task confronting contemporary health care leaders. The process of change is rarely pretty and real leaders must work through the unattractive side of implementation to actually improve.

A leader's decision making may be improved by the use of probabilistic thinking. Effective leaders must assimilate information and consider many competing agendas and options. Then, they need to decide the odds of success and failure for each option before they act.

Since leaders must provide direction with limited and generally imperfect information, probabilistic thinking may be used as a conceptual framework, integrated with a twist of judgment and experience.

One challenge of leadership is that nothing is provably certain. With this bias, here are six steps to leading improvement.

1. Develop an organizational vision with clearly outlined objectives, priorities and expectations

The essential trait of leadership is the courage to set a direction. The transition to a high-performance health care organization requires a leader to define and establish clear and specific priorities.

While numerous conflicts occur in the typical health care organization, it is the organization that devotes time to important strategic issues that will succeed in achieving its goals. Leadership requires an assessment of the probability of success for each strategic option; concurrently, real leaders must have the discipline to set the direction and remain fixed even during conflict.

Probabilistic leadership provides a framework to refine and implement the organization's vision while simultaneously improving the probability of success. Every option and decision has various probabilities of success.

The decision not to act should be deliberate. The decision to continue the same clinical processes must be associated with the same probabilities of medication errors as today.

2. Recruit the best people possible and provide necessary resources

The organization's strategy and focus should determine what is needed in a specific position. Top executives should set the expected outcomes for the position and only then find the best person to fill the role. All too frequently organizations develop a position with undefined expectations.

Unless the hiring executive can outline specific and measurable achievements, the organization has a high probability of not moving forward. Leaders must improve the probability of success for each hire by attracting the right person for the job and setting clear expectations.

The probability of choosing the right employee can be enhanced through a critical and objective process. Hiring an employee who has done the same job at a different organization may increase the probability for the initiative's success.

Similarly, someone more familiar with the organization may improve the probability of implementation due to organizational familiarity. The leader must weigh the probability of success given the overall candidate background, personality and organizational issues.

3. Hold the individual accountable for results

Providing good feedback is one of the most important, yet difficult, things a top employer can do to develop an optimal employee. Even top employees appreciate effective direction from a supervisor to assure them that their performance is in line with the organization.

Unfortunately, a common situation in health care organizations is little or no feedback followed by a discharge notice. Leading through accountability will improve the organization's probability for success.

Noted coach and advisor to multimillion dollar professional basketball players, Phil Jackson, offers this insight, "Provide positive and negative feedback on a regular basis for results." (1)

The effective supervisor must provide feedback to even the best and brightest employees. In fact, top organizations tend to cultivate an environment that optimizes strong talent and gets rid of the individuals who are unable to keep up.

Effective management of employees is the employer's most important task. In his recent Harvard Business Review article, (18) Jay Jackman provides a summary:

* Accountability is difficult, eliminating a non-performing employee is comparatively easy

* Provide regular and timely feedback to achieve results

* Don't choose popularity over accountability

The employee must understand his job and objectives. An ambiguous understanding of expectations reduces the probability for optimal results. The supervisor must ensure that the employee clearly understands expectations before the first day and then provide effective and timely feedback during the entire employment relationship.

Accountability will not happen without effort, it requires the tenacity and focus of real leadership.

1. Measure just enough to confirm improvement or stagnation 

Effective leadership and strategic planning both require measurement to better understand the organization and target markets. The challenge for effective executive teams is just how detailed the information has to be before a decision is made to move forward.

Information paralysis is a common problem in health care organizations today. Despite powerful computers, the effective leader must act on a reasonable probability of success rather than wait for statistical significance. A leader who waits for perfect information is not realistic in today's complex health care environment and may damage the organization's competitive position.

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It is critical to know what to measure. While the powerful data systems in most hospitals today can churn out reams of data, only a few pieces of information are useful in implementing improvement. By identifying the right measures to achieve the organizational vision, executives can better lead the organization to success.

While risk does exist in making decisions without full information, probabilistic leadership requires that decisions are made with the information available combined with appropriate judgment. Kathleen Sutcliffe (2) suggests, "the returns on accurate knowledge are initially positive, taper off, and then turn negative.... The way executives interpret their business environment is more important for performance than how accurately they know their environment."

The concept of leading with "good enough information" is a challenge for executives. Just as a physician sees the patient and makes a reasonably accurate, but not precise, judgment on the patient's condition and offers treatment, the executive must make decisions in a timely way given the information available at the time without unnecessary procrastination.

2. Expect and encourage productive conflict in your organization

Change is difficult. If a meeting related to any change of a system happens without any conflict, the participants have not presented their real opinions. If these conflicts do not get discussed, forward movement may never occur.

Introducing a quality initiative attempts to create positive change; however, change will never occur without at least some challenge.

Productive staff meetings should be passionate with critical discussions. If the team complains about meetings taking up time that is needed for "real work," it is a sign that those meetings are not as productive as they should be.

Organizations must create a climate and culture where the truth is heard and understood. Leaders must learn to lead with questions and not answers. The powerful must engage in dialogue and debate, not coercion.

It is very difficult for subordinates to engage in open dialogue. This can derail the improvement process. Executives must encourage employees to present their perspectives to increase the probability of improvement. Understanding alternative views is critical to improving the probability of organizational success.

3. Engage physicians and other key clinical staff

Executives must include key clinical leaders and staff in any change process. While executives can prod and support change, the real drivers of clinical change must be physicians, nurses and other staff.

Executives may attempt to inspire a shared vision through effective communication and finding a common ground. However, it is the key clinical leaders who must lead improvement initiatives in patient care areas.

The theory of tipping point leadership hinges on the insight that in any organization, once the beliefs and energies of a critical mass of people are engaged, conversion to a new idea will spread like an epidemic, bringing fundamental change very quickly. (3)

This knowledge is used in probabilistic leadership to create an atmosphere with an improved chance for change.

As organizations become more complex, leaders cannot make decisions with absolute certainty. It is the leader who understands that some decisions will improve the probability of success while others won't. It is through probabilistic leadership that executives weigh the pros and cons and probabilities of each action.

Obviously, leaders hope to make decisions with a high probability of success; however, some situations require decisions with a lower probability of success but a higher potential payoff. Some leaders choose to mix decisions with low probability but great potential with those of high probability but more modest payoffs.

The executive must balance these tradeoffs to optimally enhance the overall probability of organizational improvement.

References:

1. Jackson P, Delehanty H. Sacred Hoops. New York: Hyperion, 2002.

2. Sutcliffe KM, Weber K, "The High Cost of Accurate Knowledge." Harvard Business Review. 81(5):74-82, 2003.

3. Kim WC, Mauborgne R. "Tipping Point Leadership." Harvard Business Review. 81(4): 60-9, 2003.

Scott Ransom, DO, MBA, MPH, CPE, FACPE is the director of the Program for Healthcare Improvement and Leadership Development and an associate professor in obstetrics, gynecology, health management and policy at the University of Michigan, Ann Arbor. He is also president of the American College of Physician Executives. He can be reached by phone at 734-615-4575 or by e-mail at [e-mail].

By Scott B. Ransom, DO, MBA, MPH