What does a leader really do? (Next!).

A few questions to unpack: Are you a leader? What does that mean to you? How do you know when you are doing this thing called "leading?" When you are "leading," what are you doing?

Most of us are leaders at least some of the time, and followers at least some of the time. The experience of being led feeds the craft of being a leader. When you are a follower, what do you want from those who lead you? Do you want a paint-by-numbers kit? Or do you want challenge, permission, and invitation?

When you are a leader, what do you want from those who follow your leadership? Do you want connect-the-dots implementation? Or do you want creative and passionate engagement?

If you want passion and juice from those you lead, how do you get it?

What's the model?

Is leadership the triumph of the will of the leader, Rommel driving deep into Egypt? Or is it about creating a space for initiative, Nelson off Cape Trafalgar playing war games with his admirals night after night over the Madeira and cigars?

Is the leader the font of answers and directives, the wizard behind the curtain, Solomon in the corner office? Or is the leader a mere facilitator of consensus?

A few years ago, we interviewed a number of experienced health care CEOs, asking them what they had learned about leadership over the decades they had been at the helm of major organizations. Their answers had a surprising consistency. Gail Warden, then and now CEO of Henry Ford Medical System in Detroit, told us: "Over time, I have become more of a coach and less directive, more flexible about what I expect, more comfortable with ambiguity."

Hmmm. "Comfortable with ambiguity," "less directive." Doesn't seem to fit the Rommel/Patton/Napoleon model.

Pat Hays, who in 15 years at the head of Sutter Health brought it from $69 million to $1 billion in annual revenues, before becoming CEO of the nation's Blue Cross/Blue Shield Association, said: "In the earlier part of my career I felt that I had to be the center of all answers. Now it is more a matter of shaping the philosophy and the dialog, setting the basic strategic directions, and then getting Out of the way."

Stephanie McCutcheon, head of SSM Health Care of St. Louis, echoed Hays, saying, "I was raised to see a leader as the person with all the answers. When I was younger, often I would go into a meeting with an answer ready to go. Now I walk into meetings without answers and craft the answers at the meeting. My experience as a leader is that its my job to facilitate the development of the vision, to get the team around the table to find the answers, to pose the proper questions, to look creatively for solutions."

So, not the Solomon model either. James Reinertsen, MD, then CEO of Health System Minnesota, now CEO of CareGroup Inc., the parent of Beth Israel Deaconess Medical Center in Boston, went through much the same evolution: "In my original model, people looked to the leader to do the right thing, to be all knowing and all wise. Over my 11 years it has been apparent that this has not always been the case....At first I was under the impression that people looked to me to decide. Now when I come to a decision I am much less sure of the situation- because I now know a lot more about how complex the world really Is. Now I rarely come to a meeting thinking that it is my job to decide."

So, not Rommel, not Solomon. So what is leadership

A magic substance?

The best definition we have heard comes from Ronald Heifetz, author of Leadership Without Easy Answers (Belknap, 1994). Himself an MD, Heifetz is Director of the Program on Leadership at Harvard's Taubman Center, a lecturer in public policy at the Kennedy School of Government, and clinical instructor in psychiatry at Harvard Medical School.

When we talked to Heifetz, he said, "First of all, leadership is an activity," not some magic substance or undefinable personal quality. Since it is an activity, it can be learned: "The notion leaders are 'born, not made,' that we cannot learn to lead, is entrenched in our culture and in the way we think. And it's a dangerous idea.... People can learn a great deal about how to deploy whatever skills they do have in different contexts."

The activity of leadership consists of "mobilizing other people...to do what I call 'adaptive work.' Adaptive work can mean clarifying a conflict in values, or bridging the gap between the values that we stand for and the current conditions under which we operate. When you have a problem or a challenge for which there is no technical remedy, a problem for which it won't help to look to an authority for answers--the answers aren't there--that problem calls for adaptive work."

In Heifetz's thought, the work of leadership is not about finding answers. It's about raising the questions--not just any questions, but especially the questions that are the most difficult, questions that are not solvable by technical means, questions that are about a conflict in values.

The greatest leaders have few answers. Instead they create a space of both challenge and support in which their followers can imagine new answers and new possibilities.

How do we shut down that space of possibility? How do we create rote, paint-by-numbers organizations? By having answers. Or, more subtle than that, by expecting answers, by creating an urgency around solutions.

Of course, we need solutions. We need solutions with an urgency approaching desperation. Yet the rush for solutions collapses that "space of possibility," the ongoing conversation about alternatives and different ways of seeing. That space is more important than any particular solution, because it is the breeding ground of solutions. It is the seed corn.

Job One

For a leader, then, job One is keeping the spotlight on the gaps and contradictions in our values. Martin Luther King's Job One was keeping the nation aware of the gap between our values, as a nation founded on the principle that "all men are created equal," and our everyday experience as a nation riddled with racial discrimination. Job One for a health care CEO is often to highlight the gap between what we say we are about ("a business of caring") and our customer's experience of our institutions as confusing, frightening, dangerous places, or the contradiction between one value (such as "efficiency") and another (such as "healing").

The second task is to lay out a destination, a direction out of this values dilemma. This is King painting the image of the Promised Land, the Dream. This is the wagon master saying, "We are going to California," not the guide saying, "Steer toward the cleft just to the right of the hill with two peaks."

Running and re-creating a health care system is a far more complex task than getting to California ever was. Setting a direction, without providing a detailed pathway, creates a vacuum that sucks in new ideas from everybody involved--if the leader takes the time to see what others see.

We do not always do this, however much we may say, "I'm open to all suggestions." More often, we feel we know what the union is going to make of this, or what the doctors are going to think, or what objection the nurses are going to come up with. And often the "different points of view" are not expressed clearly, in language we are used to, taking into account the facts that we have at our fingertips. Often they are not even polite.

Recently, for instance, we sat in on the annual meeting of a health system's large "board of corporators. During the question period, a janitor from one of the system's hospitals stood up and peppered management with antagonistic questions. He was clearly well known to the management, and they treated him with polite, smiling distance. He was rude, ill-mannered, and often self-contradictory. He soon stalked out of the meeting in a self-righteous cloud.

Being heckled is no fun, and the CEO had our sympathy. Yet the heckler represented a bundle of energy, something real that was not being addressed, a bundle of possibilities and solutions that had nowhere to go. What might come from sitting down with him, asking him about his concerns, giving him more information, even asking his help in putting together meetings with other disaffected employees?

Creating a space for new possibilities

If what you're doing is simply getting others to see what you see, you are casting off everything that others might bring to the task. So half of the job of creating the vacuum is: don't fill the space with your own solutions. The other half is in the listening: The open ear of the leader creates the suction.

The third task is to remove the roadblocks and hurdles that are in the way of your followers. Each person's obstacles will be different. Even the obvious ones are not universal. One person will see a budget constraint as an absolute, another will see it as a system flaw to work around. The leader cannot see what each person's roadblocks are. And the followers cannot always name them. Only if you have diligently maintained the open space for people to speak will you be able to ferret out what the real barriers are, and help people find ways around them.

When we don't do this well and deeply, we see other people--each other--as the barriers.

Leadership is necessarily messy, contingent, and opportunistic. Leadership is about direction, not answers. It is about creating a space for creativity and passion, not about providing cookie-cutter solutions.

True leadership is rare in health care, yet much of our future depends on growing leaders who can make health care robust, responsive, and big-bellied with ideas.

Joe Flower is an internationally recognized health care futurist. Patrice Gullaume is a personal and executive coach. Their company What If... is dedicated to bridging the gap between what is and what's possible. What If...offers a technology of inquiry that helps people and organizations imagine and build toward their own best future. You may contact the authors by calling 415/924-5036 or via email at [e-mail]