Session 31
Leading Adaptive Change to Create Value in Healthcare
Val Ulstad MD, MPH, MPACEO Partners at Cascade Bluff LLC
Leading Adaptive Change to Create Value in Healthcare
© 2016 Health CatalystProprietary and Confidential
Poll Question # 1
4
Adaptive WorkWhat percentage of your work is adaptive?
1) 0% to 25%2) 25% to 50%3) 50% to 75%4) 75% to 100%5) Unsure or not applicable
• Describes what people do.
• Describes what people exercising leadership can do if they see differently.
• A way of developing a shared language to describe group dynamics.
• Describes a way to be an active, engaged, and organizational citizen.
• Really resonates with professionals in healthcare.
Why Adaptive Leadership?
Adaptive Leadership
People adapt more successfully to their environments by facing painful circumstances and developing new attitudes and behaviors.
Work of Ron Heifetz, M.D.
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
CONCEPT: Productive Range of Tension
I am so terrified I don’t understand a word you are saying.
I don’t want to hear any more bad news.
I can’t make sense of any of this.
I came for a pill or gadget to fix this.
I am looking to you for guidance and honesty.
I understand the reality of my condition.
I understand what I need to do.
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
CONCEPT: Productive Range of Tension
Productive Range
Threshold of learning
Limit of tolerance
Human Systems
Productive Range
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Time
Tens
ion
of c
hang
e
Threshold of learning
Limit of tolerance
CONCEPT: Types of Situations Requiring Leadership
Technical: Apply abilities that already exist in the system’s capabilities.
Adaptive: People deeply and broadly within the organization need to learn new capabilities.
The Challenge
The way things are
Address the gap
Achieving the Triple Aim
• Improved population health.• Enhanced patient care experience
(not forgetting the experience of the people who provide it).
• Lowest appropriate total cost of care.
c
The hard work ahead demands we create value and stay resilient.
Why is it so hard?
Properties of Adaptive Challenges
• Gap between way things are and desired state
• Varied points of view
• Involves facing loss
• Requires trying things
• Requires difficult learning
• Takes longer than technical work
• New competencies must be developed
• Generates disequilibrium, distress, and work avoidance
• People with problems have problem-solving responsibility
Wicked Problems
Technical challenge
Adaptive Challenge
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Technical and Adaptive Challenges
Technical and Adaptive Challenges• Flow charts• Affinity diagrams• Decision analysis tools• Measurement tools
Technical pieces are necessary but insufficient for adaptive work.
The conversations and insights they stimulate will help with the adaptive work.
The most common cause of leadership failure is treating an adaptive challenge with a technical fix.
Distinguishing Between Technical and Adaptive Challenges
• You’ll know it’s adaptive work…
• When people’s hearts and minds need to change; not just their preferences and routine behaviors.
• If the process of exclusion occurs when a technical approach has not worked.
• If conflict persists. Conflicts are symptoms; not the actual problem.
• When it becomes a crisis (crisis is often a good indicator).
KEY QUESTION: What is the work?
Start somewhere meaningful and manageable
The way things are
The way things need to be to create a better future
Diminish the gap
Adaptive Work
Adaptive leadership: The activity that mobilizes people to perform needed adaptive work.
The way things are
The way things need to be to create a better future
Diminish the gap
Adaptive WorkYou
KEY QUESTION: Who Cares About the Work?
Organizations are illusions; they are just groups of relationships.
- Parker Palmer
c
Courtesy of Judy Brown
Definition from Judy BrownNOT
DialogueDialogue is a form of communication based on the value of eliciting many perspectives in order to understand, and thus take wise action, in complex dynamic situations. It requires strengthening critical leadership and communication skills, among which are listening, awareness of one’s inner process, respect for differing points of view, tolerance of ambiguity, speaking from the heart, and one’s own experience.
Why Practice Dialogue?
• Increase the intelligence of the group
• Build and maintain trust
• Support sustainable and sustaining relationships
• Work together more effectively
• Address adaptive challenges (those for which there is no technical fix)
Key Practices
• Pay attention• Set a great example • Celebrate and learn from what
is going well• Talk about why you think this is
important• Ask questions• Listen
Stakeholder Analysis
• A critical success factor for any improvement project is your ability to identify those who will be impacted by your work; address their concerns and gain the appropriate level of support.
• It is an important first step in your engagement strategy.
• Will need revisiting regularly as conditions change.
Keep Satisfied
Meet Their Needs
Key Player
Manage Closely
Monitor
Minimum Effort
Keep Informed
Show Consideration
Low High
High
Low
Interest of Stakeholders
Pow
er /
Influ
ence
of S
take
hold
ers
Stakeholder Power & Interest GridCan help you prioritize
© 2016 Health CatalystProprietary and Confidential
Authority Leadership
• Leadership is an activity.• Authority, power, and
influence are tools but do not guarantee leadership; they are necessary but insufficient.
There is a difference between the role of authority and the exercise of leadership.
CONCEPT
is a critical resource for leadership even when/if you have a big title
Authority(whether formal or informal)
is necessarybut insufficient for the exercise of leadership
is the ability to constructively influence
Adapted from C. Dwyer, The Shifting Sources of Power and Influence, Amer Coll of Phys Executives, 1992
Developing Influence• Assess their capability• Help them see what’s in it for
them• Earn trust• Speak to their perception of cost• Acknowledge their perception of
risk
Your Success at Influencing Another Their capability to do what you askPlus +• (Their Perception of Potential
Benefit X Their Perception of the Probability of the Benefit Really Happening)
Minus -• (Their Perception of Cost + Their
Perception of Risk)
It’s all about perception.
Developing Influence
You will tend to exaggerate the• Potential benefit to others• Extent to which you are trusted
Others will tend to exaggerate the• Potential personal risk• Potential personal cost
Adapted from The Shifting Sources of power and Influence, Dr. Charles E. Dwyer
Perception Matters
Adapted from S. Covey Sr., Seven Habits of Highly Effective People, Simon and Schuster, 1999
Emotional Bank Account
Esteem Acceptance Respect
Emotional Bank Account Balance Sheet
CourtesyKindnessHonesty
Keep commitments
DiscourtesyDisrespectInterrupting
OverreactingCausing another to feel
ignoredBecoming arbitrary
Betraying trustThreatening
Esteem
Acceptance
Respect
Adapted from S. Covey Sr., Seven Habits of Highly Effective People, Simon and Schuster, 1999
Build Up The Emotional Bank Account
Understand the individual• Seek to understand the way you want to be
understood
Attend to the little things • Be kind and courteous
Keep commitmentsClarify expectationsPersonal integrity• Walk your talk• Be loyal to those not present
Sincerely apologize when you make a “withdrawal”
Adapted from S. Covey Sr., Seven Habits of Highly Effective People, Simon and Schuster, 1999
cPeople will trust you when you fulfill their expectations (their wants and needs).
Your balance increases in their emotional bank account.
People will distrust you when you fail to fulfill their expectations (their wants and needs).
Your balance decreases in their emotional bank account.
Exercising leadership to do adaptive work means
disappointing people’s expectations at a rate they can tolerate.
Exercising leadership to do adaptive work means
disappointing people’s expectations (that things will stay the same)at a rate they can tolerate
(and not ignore you, try to silence you, or resist in infinitely creative ways)
A signal that you are losing influence and exceeding the amount of loss and uncertainty they can tolerate.
How to respond:• Clarify your intentions.• Refine your approach to the tensions between
perspectives (conflicts) inherent in the issue.• Try again to help the group make progress.
Resistance Passive or active
Poll Question # 2 Understanding Resistance
43
When people resist the change you’re helping them face (answer “True” or “False” for each answer):
a) They are just trying to ruin your day. b) The rate of change is too much for them to tolerate. c) It indicates that you are gaining influence.d) It means you need to try a new “test of change.”
Technical challenge
Adaptive Challenge
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Making Progress on The Work
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Technical challenge
Adaptive Challenge
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Making Progress on The Work
Distress
Distress
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
The Work
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Blame others, distract attention, denial
Blame others, distract attention, denial
The Work
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
What people will not tell you, their behavior will reveal
CONCEPT: Work avoidance is a signal of being outside the productive range of tension
Work Avoidance: Resistance
Distracting attention• Pretend to be busy• Define problem to fit your
competence• Make the problem too big• Restructure/reorganize• Meetings with information
exchange only when engagement is needed
• Pick a fight
Denial• Flavor of month
Displacing responsibility• Attack authority• Kill the messenger• Scapegoat
What kinds of work avoidance / resistance have you seen in others?
What kinds of work avoidance have you seen in yourself?
Taking a drink from a fire hoseOverwhelmed
Seems like good common sense to meI‘m with you, keep going
This doesn’t really apply to meI’m not in charge, I don’t need this
Where We Are Right Now?
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
PRODUCTIVE RANGE
HOLDING ENVIRONMENT
Work avoidance
Work avoidance
Work Avoidance: A Signal
Technical challenge
Adaptive Challenge
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Resistance
A signal that you are losing influence and exceeding the amount of loss and uncertainty they can tolerate.How to respond:• Clarify your intentions.• Refine your approach to the tensions
between perspectives (conflicts) inherent in the issue.
• Try again to help the group make progress.
Passive or active
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Your Work
Blame others, distract attention, denial
Blame others, distract attention, denial
The Work
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
What people will not tell you, their behavior will reveal
What Does Work Avoidance/Resistance Tell You?Interpreting stakeholder behavior when they are engaged about the work
Which ones are above the limit of tolerance?
Heat too high
Which ones are engaged in the work?
Heat is in the zone to keep things cooking
Which ones are below the level of learning?
Heat too low
Adaptive WorkYou
What does the work avoidance suggest?
How are those who care reacting to the work?
What Do I Do Next?
Use yourself differently. Keep people who are making
progress engaged and figure out what you need to do to reengage others.
Widen the zone of productive tension.
Use Yourself Differently
• Pay attention• Set a great example • Celebrate and learn from what
is going well• Talk about why you think this is
important• Ask questions• Listen • Reflect in action
CONCEPTReflect in Action
Get on the Balcony and Dance
c
cI’m not getting my point across...Whatshould I say next?
Balcony AND Dance Floor
Over focus on Balcony Over focus on Dance floor
Professor Osmo Wiio: Laws of Communication
• Communication usually fails; except by accident.
• If a message can be interpreted in several ways, it will be interpreted in the manner that maximizes the damage.
• There is always someone who knows better than you what you meant by your message.
http://yle.fi/uutiset/professori_osmo_a_wiio_on_kuollut/6505579
“The single biggest problem with communication is the illusion that it has taken place.”
George Bernard Shaw
http://libapps.libraries.uc.edu/exhibits/irish-lit/twentieth-century-writers/
Be curious
Courtesy of Judy Brown
c
Mine Other’s
Intention
Impact
Other’s impact on me
My intention Intention of other
My impact
Harvard Negotiation Project
c
Mine Other’s
Intention
Impact
X
X
Harvard Negotiation Project
c
Mine Other’s
Intention
Impact
X
X
Our assumptions about intentionsare often wrong
Good intentionsdo not make bad
impact unimportantor irrelevant
Harvard Negotiation Project
c
Mine Other’s
Intention
Impact
This is what I meant
This is how it felt/seemed to me
Is that what you meant?
How did it feel/land with you?
Harvard Negotiation Project
cWhat they think they heard is much more important to the listener than
what you are sure you said.
The perception of the other is just as true as what you intended to say.
Practical Approach• Work closely with those
that offer resistance; they’re sending you a signal.
• Try to understand other people’s resistance to change.
• They may know something you need to understand!
What Do I Do Next?
Use yourself differently. Keep people who are making
progress engaged and figure out what you need to do to reengage others.
Widen the zone of productive tension.
Begin to Plot a Strategy• What do you need to do to make
progress?• What can you do to lower the
distress on those above the limit of tolerance?
• How can you maintain engagement of those currently engaged in trying to make progress?
• What can you do to raise the distress to a productive level for those below the level of learning?
c
Talk About It:
Think about a time when the heat was too high.
What did you do to bring things to a productive level of tension?
Lower the Heat
• Validate feelings; acknowledge loss.
• Simplify and clarify.• Restore, add, or reallocate
resources.
Talk About It:
Think about a time when the heat was too low.
What did you do to bring things to a productive level of tension?
Raising the Heat
• Raise the standards.• Increase accountability.• Change the task to something
more motivating. • Refocus on higher, more widely
shared, and compelling purpose.
PRODUCTIVE RANGE
HOLDING ENVIRONMENT
Work avoidance
Work avoidance
Technical challenge
Adaptive Challenge
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Are You Reading the Signals?Work avoidance signals being OUT of the productive zone
A signal that you are losing influence and exceeding the amount of loss and uncertainty they can tolerate.
How to respond:• Clarify your intentions.• Refine your approach to the tensions
between perspectives (conflicts) inherent in the issue.
• Try again to help the group make progress.
Resistance Passive or active
Keep an Experimental MindsetExercising leadership requires keeping an experimental mindset.• Work avoidance looks the same when the heat is too high OR
when the heat is too low.• Keep rechecking your assumptions.• What looks like laziness may be exhaustion.• If what you try makes things worse, then try the opposite.
Poll Question # 3Lowering The Heat
82
How do you lower the heat / bring things to a productive level of tension?
a) I validate feelings / acknowledge loss of the way things used to beb) I simplify and clarifyc) I restore, add, or reallocate resourcesd) All of the abovee) Unsure or not applicable
What Do I Do Next?
Use yourself differently. Keep people who are making
progress engaged and figure out what you need to do to reengage others.
Widen the zone of productive tension.
c
OPTIMAL STIMULATION Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Productive Range of Tension
What else would you add?
Optimal Stimulation• Work as a team. • Learn new ways to approach problems.• Create environments in which others can solve problems.• Help facilitate change in thinking and behavior.• Help the “light bulb” to go on.• Watch people transform while doing transformative work.• Help others gain confidence and feel energized by their success.
c
Resilient
Responsive
Apathetic
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Overwhelmed
Productive Range of TensionZone of resilience and responsiveness
APATHETIC
OVERWHELMED
• I have a chance to work more effectively and efficiently
• I have a chance to constructively influence making care better
• I have a chance to learn improvement methods and skills to enhance my leadership
• I am asked to lead and I do not feel like I have enough authority to lead
• This is one more thing to juggle and I am already dropping the other things I am juggling
• My heart is not in it but I’m here• Standardization is cookbook medicine – I am
wasting my time
RESILIENTProductive Range
RESPONSIVE
Making Progress on Difficult Problems
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
c
Strain of uncertainty
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Strain of uncertainty; compressed adaptive capacity
Distressed System
“Can you endure your uncertainty until it shows you another way?”
Mark Nepo
“When nothing is sure, everything is possible.”Margaret Atwood
c
Strengthening Your Capacity to Tolerate
Uncertainty
c
Learn to not take it personallyEven when it is meant to feel personal
It’s Not Personal
95
People attack when you represent a message they do not like.• You are disappointing their
expectations at a rate they can’t tolerate.
When you take attacks personally you: • Conspire to take yourself out of the
action.
What You Do Next Matters
96
ReframePlace the focus back on the message and the issues.
Ask a question Your management of an attack (not substance of the accusation) determines your future effectiveness.
Use trusted colleaguesOthers can help you see what you have come to represent.
© 2016 Health CatalystProprietary and Confidential
Don’t go it alone
Partnerships
Allies • Share some part of the
professional experience (has a competing interest).
• Care about the issue.
Confidantes • No competing interest.• Care about you.
Help you get on the balcony and see what you may have difficulty seeing.
Regain courage and perspective
Reaffirm a deeper sense of self and purpose
Restore spiritual resources
Feel physically and psychologically safe
Reflect and capture lessons
Find Sanctuary
“What boundaries do I need to put in place so I can work from a place of integrity and extend the most generous interpretations of the intentions, words, and actions of others?”
“I am going to be generous in my assumptions and intentions while standing solidly in my integrity and being very clear about what’s acceptable and what’s not acceptable.”From Rising Strong by Brene Brown, Random House, 2015, p. 123
Brene Brown
Common belief:Those who resist don’t care
Distressed System
Productive Range
Threshold of learning
Limit of tolerance
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
APATHETIC
OVERWHELMED
RESILIENT RESPONSIVE
Strain of uncertainty; compressed adaptive capacity
Predictable Fundamental Human Error of Attribution Others behave badly because of a character flawI behave badly when I am in a tough situation
Nobody behaves badly from a place of strength
Start with Compassion
When you don’t know what to try first, lower the heat.• Validate feelings; acknowledge loss.• Simplify and clarify.
• Address the technical aspects• Break the problem into parts
• Restore, add, or reallocate resources.• Temporarily reclaim responsibility for
tough issues• Give your attention• Take stock of what is available • Allot more time; enrich knowledge and
skills
Nobody misbehaves from a place of strength.
Give What You Need
• Empathy• Appreciation• Recognition• Honest feedback• Respect• A sense of connection to
meaningful work
• Validate feelings; acknowledge loss.• Simplify and clarify.• Restore, add, or reallocate resources.
Enhancing Resilience Raises the Threshold of Tolerance AND Lowers the Threshold (Enhances) of Responsiveness
Increased adaptive capacity
Lowered threshold for responsiveness
Raised threshold to continue to be resilient
Desired State: Increase Capacity for Adaptive Work
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Widen range for holding tension of uncertainty productively
Activate and Expect Responsiveness Through Clear Boundaries
Raise the Heat:
• Raise the standards.
• Increase accountability.
• Change the task to something more motivating.
• Refocus on higher, more widely shared, and compelling purpose.
Build trust by doing new work togetherin new ways, equipping yourselves for resilience and responsiveness
Increase Capacity for Adaptive Work
Increased adaptive capacity
Lowered threshold for responsiveness
Raised threshold to continue to be resilient
Time
Tens
ion
of c
hang
e
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.
Holding tension of uncertainty productively
Technical work• Clear answers, minimal uncertainty
• Straightforward, few big choices
• Execute via precise instructions
• Requires hands, feet, and mouths
• Focus on task
• Linear, demands precision
• Runs smoothly
Adaptive work• No clear answers, often high uncertainty
• Time consuming, difficult choices (losses)
• Demands lots of conversations
• Requires hearts, eyes, and ears
• Focus on people
• Demands creativity
• Conflict, distress, and fear
Leadership Challenges
New Insights?Technical Work vs. Adaptive Work
Poll Question #4
Adaptive WorkWhat percentage of your work is adaptive?
1) 0% to 25%2) 25% to 50%3) 50% to 75%4) 75% to 100%5) Unsure or not applicable
Concepts
• Productive range of tension.
• Difference between technical and adaptive work.
• Difference between role of authority and the exercise of leadership.
• Work avoidance as a signal of being outside the productive zone.
• Reflect in action.
• What is the work?• Who cares about the work?• How are people who
care about the work reacting to it?
• What do I do next?• Use yourself differently• Regulate distress• Widen the productive zone of
tension
Leading Adaptive Change
Lessons Learned at the Frontline• General relief when people understand the difference
between technical and adaptive work - and realize that something is not wrong with them because the work is hard.
• Lowering the heat does not mean letting people off the hook; it means giving people what they need to make progress.
• Understanding that the data itself tells a story.
• Need to start with believing people are doing what they are doing for a reason – be curious about intentions and don’t get distracted by impact.
• Speak to what brings people to healthcare and what keeps them in healthcare.
2 hours later…What do you see differently?Will anything be different in your approach to your work?
Analytic Insights
AQuestions &
Answers
117
What You Learned…
118
Write down the key things you’ve learned related to each of the learning objectives after attending
this session
Thank You
119
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