The head of The family Medicine Department, University of Minnesota has a long history of developing physicians who have been influential in the field. He is committed to developing a self-sustainable program that will continue despite the external challenges. But the latest round of challenges before him is immense. Family Medicine lies at the cornerstone of healthcare reform. Yet state budgets to support Family Medicine resident education have been slashed by two-thirds. Hospitals and other healthcare systems that utilize and support resident training are unable to fill the void. Faculty have not received pay increases in several years, despite being asked to do far more. Indeed the business model of simultaneously providing care to the indigent and developing the next generation physicians is in jeopardy.

The intervention

The head of the department of Family Medicine decided he needs greater leadership support from his people. He provided three days of Strategic Leadership Tools™ training from The Leader’s Toolbox, Inc. followed by the formation of Toolbox teams who are expected to utilize the learning to address some of the department and clinics most pressing issues. These teams receive coaching support to ensure they use the tools correctly and focus on the right issues. The first teams addressed were tasked to develop plans and recommendations around the question: How do we building strong local leadership teams that can more quickly and effectively implement change. A second group will focus on the challenges of creating advanced family medicine practices given the new healthcare environment. The resultsThe return on this investment has already been significant…despite the fact that the training and subsequent Toolbox team work has just begun:

1. During the training portion of the program the local clinic leaders told the head of the department that they would shoulder more of the management responsibilities in order to help him devote more time to address the pressing strategic challenges. Local and senior department leadership have started to change their agendas and refocusing their work.
2. The head of the department brought together the leaders of several external organizations and used the learning to resuscitate one of the residency programs that was about to be dismantled
3. There is greater realization of the similarity and differences between the clinics…and the advantages of working more closely. There are instances of one clinic leader providing supportive advice for another clinic leader.
4. One of the clinic physicians called a meeting with her program director and the head of the department to announce her resignation from the program because she had been unsuccessful in her attempts to institute a new program within the department. Her program director used some of the learning from the Strategic Leadership Tools program to help her understand why her attempts had been unsuccessful and promised to provide leadership coaching. The physician was grateful for the interaction and has decided to remain with the program.
5. The tools are starting to be integrated with the residency education so that the residents will learn leadership and healthcare related skills
6. Leaders across clinic sites are starting to mentor one another. There is a greater sense of community among the leaders that is starting to emerge.
7. Tiger teams are addressing the challenge of building local cohesive and effective leadership teams at the clinic levels. Shortly they will address the issues around developing the programs and infrastructure necessary to create advanced family medicine.

Implication The resolution of the healthcare crisis cannot be solely borne by public policy. Instead it requires increased leadership capacity at all levels…including local physicians who become more easily adept at implementing change. We need to implement leadership development programs that are relevant, time-efficient, and yield results.

The fundamental Challenge of Healthcare Reform

Imagine that you, a non-physician, were given a white coat and told to diagnose and subsequently treat a patient who was close to death. That analogy is similar to physicians who almost universally have no formal or practical experience to lead and implement massive change. It is actually worse than that.

Now imagine that you are an accomplished tennis player. The road hasn’t been easy. There were countless hours of practice, tournaments, and individual coaching. You learned the rules and decorum which everyone agrees and adheres to. Then one day you are selected to be on the soccer team of a foreign country. No longer is success based solely on your individual performance or capabilities. This is truly a team sport. There are new rules, language, and skills which are generally followed. In some countries when the fans are unhappy with the result they are not only rude, but sometimes come out to the field ready to do battle.

This describes the transition faced by many healthcare leaders. They are all individually accomplished and have received recognition and often their leadership posts because of their technical capacities. But the game, language, rules, and the nature of the interaction with the players have changed. BUT TYPICALLY NOT THE SKILLSET OF THE PHYSICIAN LEADERS!

Already overworked, less appreciated by their professional peers, and overwhelmed by the task in front of them, physician leaders on the front line juggle the challenge of meeting the requirements of the current game, treating patients and meeting the financial objectives, and build the capacity to play in a new, yet undefined game. Once exception: The rules of soccer have been defined. The rules of engagement and winning are clear.

The sparse data suggest that the majority of new programs of new projects are unsuccessful. More than 60% of healthcare balanced scorecard initiatives fail. Similar results are experienced with LEAN implementation.

Fundamental healthcare strategies

What is missing is a platform for change. Here are several elements that are almost universally needed.

1. Establish clear organization objectives. Although the healthcare policy is far from settled, we know that the new models of care require

• Higher levels of collaboration and openness for new possibilities
• Greater emphasis on the use of data in decision making and evaluation
• Greater emphasis on core organization competencies
• Higher levels of partnership between healthcare related entities
• Greater use of technology
• Higher levels of employee engagement

2. Develop more highly skilled leadership at all levels to plan and execute the work require the ability to

• Juggle the realities of the current world while building a new one
• Work in highly ambiguous, often contentious situations
• Develop common ground with essential stakeholders who have competing agendas
• Engage fellow physicians and staff who are disillusioned and burnt out by the current system

3. Redistribute work

• Create high performing teams of care
• Re-allocate work so that physicians focus on those areas that require the greatest skill and payback
• Build the capacity of people to work together in team environments

These three capacities represent the essential building blocks for healthcare reform…regardless of policy specifics. They are all within the purview of existing organizations to accomplish. They require only the resolve of senior leadership to put them into place. Those organizations that possess these three capacities are far more likely to be able to adapt to an uncertain future.

Minnesota welcomes you

Here in Minnesota we are just hours away from a government shutdown. The two political parties are playing chicken with one another and it appears that the citizenry is about to lose. The night before the deadline, the two sides called it a night…and no new talks are scheduled. For those of us who have lived here for several decades we cannot understand how we got to this point. Before I moved here I always wondered what kinds of people could tolerate that awful climate and wondered whether there was actually civilization so far north. We have a saying. “It’s harder to get people to come to Minnesota than to get rid of them.”

What made this such a wonderful place despite the climate is the willingness of people to see a larger good and to work toward the benefit of the whole. At the end of the day people were willing to come together for the greater good. Perhaps it was part of the culture of the predominately Scandinavian culture, whatever it was, this was a great State. We had great government, schools, infrastructure, theater, etc.

Now each party espouses similar values, but the actions seem otherwise. We have moved from a government working philosophy of pragmatism to dogmatism. Each side has a worldview that they want to realize and in the process miss the value of the other. As a result of the two sides digging in, the real issues are not being tackled. If the amount of time people had to spend for the preparation of the shutdown could have been used on some real issues, more progress could have been made.

Unfortunately for the country, this is not singular to this state. A congressman who I have had the pleasure of working with noted that he was proud to serve in the institution in the past…but that the veil of civility has been withdrawn. It is no longer a place where people can easily work across the aisle. It has become a fight against the other party rather than accommodating differences for a better outcome.

Dogmatic vs. pragmatic. How did we get here? How do we get out of it? We citizens on the sidelines watch in fear as those responsible for the wellbeing of our institutions struggle an often senseless fight. Your thoughts are welcome.

Following the original published version, a reader suggested the following video which I found to be marvelous. It’s dated, yet current. http://www.linkedin.com/e/fw7pwr-gpjwwhay-2r/plh/http%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3DLbWCjQ5L0ZY/38NH/

Most people:

• Don’t think they can take on any more work
• Feel that much of what they do is less important…but expected to be completed anyway
• See there are longer range issues to be addressed, but these are not valued by their managers
• Feel there is no way out of the box

What I have found:

• People make assumptions about what/why something has to be done without checking them out. Some work can be eliminated by sitting down with the boss and redefining the work
• People believe others cannot do their work….so they don’t delegate as much as they should. Challenge those assumptions. Is it because others can’t do the work or you won’t let go because it’s your baby?
• Many of the hours spent in meetings could easily be eliminated with good meeting practices and discipline. Become merciless about your meeting time. Learn good meeting management practices and use them.
• There are times when people could change the expected/typical task and turn it into meaningful work. Determine the biggest contribution that could be made right now, on this task, in this meeting, with these people. Push the envelope.

Follow these four practices and you will find:

More time, meaning, satisfaction, and higher levels of engagement for you and those around you.

Fighting gravity is not easy…yet it and must can be done to achieve a purposeful life.

If you have success stories would love to hear about and share them.

Understanding the nature of the leadership work from a different perspective by focusing on the work itself may be more helpful than understanding the psychological makeup of the leader. It provides a shortcut to getting us to where we need to be.

A recent article in Strategy and Business provides an example. “How to Balance Power and Love,” by Art Kleiner provides an interesting dialogue with Adam Kahane who is the author of Power and Love: A Theory and Practice of Social Change. The author asks the question of how leaders choose between the challenges of getting things done with the need for building relationships. Most people choose to emphasize one over the other as a preferred style which reduces the effectiveness of their leadership. One leader is able to find the balance this way. “When I was tempted to be tough, I tried to be compassionate, and when I felt inclined to be compassionate, I tried to be tough. Not many people understand how to keep those drives in such a dynamic balance.” Doing the opposite of one’s natural emotional inclinations is a practical and powerful approach to creating more adept leadership capacity.

I have been a coach for several decades…and I have never used the Meyers Briggs, DISC, or any other personality assessment as a major tool for an individual’s professional development. It is not that I am against personality assessment…I was a psychologist and had evaluated people using a number of psychological instruments as we called them. They were helpful and provided insight. But the scores almost never changed anyone’s behavior. Consequently the money spent on such instruments fails to impact bottom line performance.

What people need is to understand who to respond to specific circumstances. They need a wider repertoire of behaviors they can call upon rather than rely on the natural impulses or what they have learned from previous work or family experiences.

One of the most common reasons I see people in my coaching practice is the difficulty people have of moving from one organization level to the next higher one or the shift from moving from one organizational culture to another. As highly respected  coach and author Marshall Goldsmith notes in one of his recent books, What Got You Here is Not Going to Get You There.

In order to successfully address more complex issues people need:

• A new language, tools and processes to understand and process more complex challenges
• A broader range of skills and behaviors to work with people in more effective ways
• Higher levels of personal insight, compassion, and emotional intelligence
• A broader and more comprehensive value structure

In short what people need is not necessarily an personality assessment, but they need to understand that there are more ways to skin a cat. They need multiple lenses to see the world. They need the opportunity to learn and practice new approaches. That is how we humans learn. We need to learn that we can both be powerful and love at the same time.

I recently came across an article from Chief Executive Officer Magazine describing the most important characteristics for leaders to possess based on a 2008 survey conducted by the Hay organization. The article begins noting, “Only a handful of organizations have even begun to tap into their primary resource, their people, much less give them the means to do what they are capable of doing.”

So what do leaders feel is valued? First tier of valued competencies are strategic thinking and execution. Second tier: Decision-making, technical competence and team work. The rest on the list are far less valued. What does this imply?

Percent that value the characteristic most

Strategic thinking is almost always associated with leadership. No surprise here. Unfortunately how strategic thinking is defined on the ground varies greatly. In some places it means being able to anticipate markets, trends, etc. and then acting accordingly. In most places the operational definition is being able to survive and make good short term decisions. If you want to disagree with me, I would love for you to prove me wrong. I wished it were so.

Let’s look at the items on the survey that fell to the bottom…capacity to learn, resilience, creativity and emotional intelligence. First, I would argue that if you didn’t possess these skills, if they were not nurtured, it would not be possible to think and act strategically. It is ironic to me that the qualities associated with individual great leaders (Washington, Lincoln, Ghandi, you get the point), possess these characteristics. Yet when looked at from an internal organizational/institutional perspective they are not. Why the disparity? Why are the qualities of individual great leaders not valued inside organizations?

So it’s 2008. The United States is going through unprecedented economic turmoil. What do organizations value in their leaders—short term action, execution and decision-making. They don’t value sitting back, trying to understand the massive changes taking place in the economy. They don’t ask their leaders to demonstrate resilience. They don’t ask them to have the emotional intelligence to respond in ways that can help see, feel, and think more calmly and broadly. We all agree that 2008 is different world than 2000. How can our leaders develop new approaches, solutions, relationships without more creativity, emotional intelligence, and resilience?

Why despite the need for these personal and interpersonal characteristics are these desperately needed characteristics undervalued? Two thoughts immediately come to mind: Fear and structure.

Fear

Many years ago I went tobogganing. It was midnight. The hill which I was supposed to tackle was total ice. I had never been on a toboggan in my life. Every voice inside me screamed, “This is a mistake.” Yet, when it was my turn, I ignored common sense; I went down alone, in the dark, no control. I saw that if I maintained my present course, I would smack directly into a tree. Do I hold on or jump off? I know I am going to hit the tree and have a very hard stop if I stay the course. But I don’t know what will happen if I jump off the toboggan.  In the course of less than a few seconds I made my decision… the wrong one. I stayed with what I knew versus take the risk of jumping off and landed in the hospital instead of a snow bank.

Staying with what we know. Focusing on the short term. Making it through the day, the week, and the quarter is holding on to a toboggan that may run directly into a tree.

Without resilience, emotional intelligence, and the capacity to learn, we find most leaders hang on till the crash. The survey results explain why we are in the economic situation we are in.

Consequently as the article notes in its opening, only a handful of organizations have even begun to tap into their primary resource, their people, much less give them the means to do what they are capable of doing.

Structure

Every organization structure has a downside. For example, in a democracy, there will always be inflation. Governments will spend more than they have because the elected representatives, who seek reelection, want to demonstrate the value they serve their people by giving them a greater share of money from the central bank. For those familiar with systems thinking, it is the tragedy of the commons.

Every organization has a hierarchy. In a bureaucratic organization Bob Dylan’s song becomes reality. “You gotta serve somebody.” Everyone focuses on pleasing the boss. Even the CEO has a boss, the Board. So we all want to look good. The higher one goes the more perfect and strong, we have to look. This fact is reinforced by our cited survey.

Unfortunately as each person seeks to be perceived in an acceptable light, the result is greater stress and short term orientation. In many organizations senior leaders don’t want people who are resilient, can think for themselves because that might challenge the perception that they are less capable as leaders. It also may be perceived as taking time away from focusing on now.

Recently the person who runs a leadership development program in a university setting mentioned to me that he has noted a trend over the past several years. People are being sent to his leadership development program not prepare them to be great leaders, but to be great managers.

I’d welcome your thoughts and reactions.

When I was young, my dad used to take me to the auto show in Atlantic City New Jersey. It was a special bonding time between the two of us. I liked seeing the over-sized cars with the large fins and the cavernous occupant space. There was one car however that bucked the trend. It was tiny. So small in fact that I couldn’t imagine how a normal person could fit into it. It was produced by a new Japanese company called Honda. I imagined only the Japanese use such a contraption. Soon it outpaced the sales of the U.S. behemoths.

Healthcare leaders face a similar juncture. We have large systems that must adjust to new realities. How do we move from the large luxurious to the sleek and efficient?

So what is a healthcare leaders supposed to do? How do you build a future when it is only an intangible dream? At this point an ACO is a concept. Like a concept car at the auto show, we go wow, look at the wiz bank things coming in the future. We do know that the intent of the legislation is to reduce costs, increase access, and improve provider performance and patient outcomes. A deeper understanding leads one to understanding that all the stakeholders now sit in a changing arena while the umpires are making up the rules as we go.

We believe that regardless of how the issue plays out, it is clear that future effective implementation of the mandate requires the ability of organizations to improve in at least four areas:

1. Physician leadership
2. Ability to effectively implement and execute any kind of change.
3. Ability to work beyond historical organization boundaries
4. Stronger core technical and business competencies

• None of these areas require government action.
• All of these can be learned and require relative limited financial resources
• All of them start with a decision to do business differently

A recent American College of Physician Executives survey underscores the point.

There is much that can and needs to be done now. The U.S. big three automakers seem to have recently gotten the message—unfortunately almost at the point of their demise. Nevertheless they have learned from their foreign competitors and made the transition.

Can healthcare organizations learn their lessons before it is too late? Can they take a stronger role to chart their course rather than rely on government to plan the trip for them?

We believe that it is possible…for those leaders that display the courage to do so.

The ACPE article can be found at:

net.acpe.org/MembersOnly/pejournal/2009/NovDec/Johnson_Carrie_1.pdf

The professional responses to the feelings of stress traditionally have been:

1. Make sure you have some time with family or do the things that are personally meaningful to you
2. Learn how be more productive—do more stuff in shorter time and focus on the things that are important
3. Get exercise—or take a yoga class, but whatever you do, breathe deep
4. Confront the elephant in the room
5. Learn how to interact more effectively with others

These are all meaningful strategies that lead to greater work/life effectiveness and better health. The suggestions above are helpful and typically deal with the symptoms and not the cause of the issue. In my more than 25 years of coaching individuals I find that the source of people’s concerns typically center around these four areas.

How do I fit in?

Organizations are complex places. Role descriptions, project plans, performance appraisals, etc. are designed to provide structure to help people figure out what is important and what they are to accomplish. The reality is that the stated agenda is often sublimated to the corporate culture, the style and needs of one’s manager, and the internal political situation. The resulting ambiguity is exacerbated by changing market circumstances.

This is a far more complex stew than we are prepared to address. There is the formal agenda and the informal system which require navigation. Speaking for myself, being an only child has not helped me navigate that experience. Formal coursework, even as a psychologist, provided minimal insight—when you are on the ground.

Most people want to do a good job, do the right thing and please their bosses, but many find it hard to meet the stated and unstated expectations. Knowing how to fit in drains a lot of psychic energy.

How will I ever get this work done?

Most people are significantly challenged to accomplish the work that has been prescribed for them. Time management programs can be helpful here….but I find that people are working extra hard on things that really don’t matter…to the bottom line or the customer. Want proof? Companies that have laid off tens of thousands of people are still prospering. Ask any of the laid off people what they were doing and they might justify the value of their contributions. At the end of the day, for many of them and their organizations, it didn’t matter.

What does my boss think of me?

Most voluntary exits occur because people cannot figure out how to jive with their managers. Despite the massive investments in many organizations to improve manager interaction, it still is up to the individual to figure out how to deal with the idiosyncrasies of their bosses…a challenge made far more difficult because their bosses suffer from the same stress issues as the rest of us.

I have some great ideas, and no one will listen to them.

Organizations spend significant amounts of money to hire the best people they can find…and then expect them to fit into the existing corporate culture. These people typically have never been schooled how to “sell” an idea. So they go about this all the wrong way, get discouraged because no one is listening, and then leave in frustration. What they do not realize is that whether the idea was good or not had nothing to do with the decision not to proceed. It was how it was gift wrapped and shipped.

What’s going to happen?

Technical knowledge doubles every two years. They are even finding that microbes can exist on arsenic…who would have thought. Even companies on the Fortune 100 list can sink like a stone. There is little certainty or stability. We feel vulnerable and would like to control the future, but know it’s not possible.

What’s the antidote?

Exercise, understanding how to relate better, using time more productively, and being clear about expectations are clearly valuable strategies to dealing with stress. In the 21^st Century however, they are insufficient. If we want people to become more customer centric, adaptable, highly effective and engaged, then we need to better understand how to address the kinds of stress described above

In Part 2 I will share with you additional strategies both for individuals and for organizations that can significantly reduce stress.

We consciously brought together for the first time in Minnesota the broadest diversity of participants  to address this contentious topic.

Over the day-and-a-half long event, the participants spent about a third of the time learning more about the topic from experts, a third learning new tools approaches to address the complexity, and the remaining time utilizing the new learning and tools to address the issue at hand.

Background

The challenge of properly feeding humans on the planet is one of the most critical issues facing us earthly inhabitants. Antibiotics play a central role in the solution. But using antibiotics comes at a cost…some we are aware of and some have yet to be proven conclusively. Some of the causal detrimental factors that we have assumed are not borne out by the limited research that has taken place thus far. In short the use of antibiotics is a paradox. A central challenge to our existence is to both maximize the benefits and at the same time limit the potential perils of antibiotics.

Prior to this engagement knew almost nothing about the topic. I subsequently learned a great deal not only about the topic, but once again saw first-hand the value of framing issues properly.

Ordinarily most of us come at such complex issues with a set of unchallenged assumptions, language, and incomplete knowledge. We are likely to see those who hold alternate points of view as wrong, misinformed, or maligned. When the opposing points of view are put on the table, the natural response is for the opposing perspectives to clash. Each side fights for rightness…and little good comes as a consequence. There is lots of heat and little light that emerges from the interaction.

Antibiotics utilization through the lens of paradox

The experts were very clear. Though they spoke one seeking to maximize the benefits and the other to minimize the perils of antibiotic use, both made it clear from the start–they each could have taken the other side of the question and defended their positions equally well. There was no right or wrong—resolution required embracing “both.”

We Westerners are uncomfortable with those intractable challenges that have no simple solutions. We want clear directions and easy and direct execution. For us to take an alternative path, we need different language and tools.

What brought the group together was the vocalization and subsequent realization that antibiotic use is a paradox whose implications are unclear given the knowledge we currently possess.

Outcomes of the conference

Framing antibiotics and agriculture as a paradox helped the group realize that it had far more in common. It created the space for most of the participants to realize the need to hold off judgment. It helped them realize the power of working together.

The group developed five objectives that were critical to more effectively addressing the concerns. They focused on five areas:

• Knowledge/Research Gaps
• More effective research approaches to the topic
• Creating greater knowledge and awareness of the complexities in the community
• More effective public policies and strategic regulation

Unlike most typical interest centric groups, this conference paved the way for a broad coalition to work together, using a broad spectrum of talent, skills, and interests to pursue a more holistic and comprehensive approach to this challenging issue.

Next steps

Most of the highly contentious issues facing our nation  are paradoxes. Where else could the common ground approach be utilized? The Leader’s Toolbox and the Center for Integrative Leadership continue to look for settings in which we can add more light. Your thoughts are welcome.