Leading Adaptive Change to Create Value in Healthcare

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adaptive leadershipYou’re trying to make things better in healthcare. You’re working hard to improve care, reduce costs, and improve patient satisfaction—the goals of the Triple Aim. It is hard work, though, since hearts and minds have to change, new realities need to be faced, and there is urgency to make progress. You can’t make people do this work but must help them take up the work themselves, hold their attention on it, and when the inevitable resistance arises, face it with compassion and curiosity—and try again to make progress. This is what exercising Adaptive Leadership (AL) means: mobilizing others to learn and innovate to make progress in addressing the gap between the way things currently are and the desired state you are striving toward.

AL maps the territory of human behavior, helping leaders understand what people do and how they behave when faced with change. AL is a leadership language and conceptual framework that Dr. Ron Heifetz developed to help individuals thrive amidst uncertain change. He created this way of understanding human behavior and mobilizing meaningful progress from listening to hundreds of stories and dilemmas faced by committed, hardworking leaders trying to bring about change in the world. In this tumultuous era of new reimbursement and care models—where there are many uncertainties and the changes are numerous and complex—AL is a key resource to facilitate a way of seeing the human condition and understanding what is needed to work with others.

Heifetz used his living laboratory, the Mid-Career Master of Public Administration Program at Harvard University’s Kennedy School, to develop this language and approach. Harvard’s Kennedy School is a school of public service that attracts professionals from around the world to learn and reflect on their work. It’s where I met and studied with Heifetz and realized that this way of looking at group dynamics and human behavior was a key capacity needed in healthcare leadership.

As a result of my passion for AL, I have had the privilege of working with individual leaders and their teams, medical groups, and entire healthcare organizations for the last 20 years to help them build their ability to apply these same principles in their work. AL creates a shared language that everyone in an organization can speak and understand. This shared framework can help those who exercise leadership understand and see human behavior in a new way, help make sense of resistance triggered by rapid, high-volume change, and help guide the difficult yet necessary changes required to improve outcomes.

Recognize Adaptive Work

There are two types of challenges: technical and adaptive. With technical problems, the ability to solve the problem already exists within the system and needs to be applied. With adaptive problems, people deeply and broadly within the organization/community need to learn new capabilities and hearts and minds as well as behaviors must change. Adaptive work diminishes the gap between the way things are and the way things need to be to create a better future. The most common cause of leadership failure is treating an adaptive problem with a technical fix. Technical fixes are not bad, and may be part of the solution, but are insufficient for adaptive work. When we treat adaptive work with technical fixes the problem keeps coming back, again and again. There are several examples of adaptive work:

  • Improvement in quality and safety outcomes of patient care.
  • Clinical and non-clinical healthcare service delivery process improvement.
  • Enhancement of interdisciplinary and multi-professional teamwork through collaboration on improvement initiatives.
  • Reduction of waste and minimization of variation in processes.
  • Enhancement of organizational learning through shared knowledge of best practices based on improvements.

Why are these problems adaptive problems? There is tension between multiple perspectives, difficult learning is required that necessarily involves loss and letting go of the known past as the unknown future is created, the stakeholders have problem-solving responsibility, there is no quick fix, experimentation is required, and people get scared and overwhelmed, and resist change. Budgets are another example of adaptive work; they seem technical—just math problems. Why, then, is everyone so tense at budget time? Difficult discussions, tradeoffs, and disappointments happen at budget time: this is the adaptive work. Generating data is technical work but using data to have conversations about care and build collaboration to improve and transform is adaptive work.

Exercise Adaptive Leadership with Influence—Not Just Authority

Having authority, whether formal (a job description or title) or informal (through influence), is necessary but insufficient to the effective exercise of leadership. Having authority, power, or influence alone doesn’t guarantee leadership. Leadership is an activity that mobilizes others to do adaptive work: it helps others see what they need to do and supplies them with the tools and feedback they need to make progress.

Formal authority (command and control) is sufficient for technical work. Constructive influence is required for adaptive work—formal authority is insufficient. How one uses authority is key. The exercise of leadership requires profound clarity about what the work actually is, a clear understanding of the current state and characteristics of the desired future state; the ability to hold people’s attention on the work at hand, tolerate ambiguity and allow emergence, keep tension relative to the work at hand at a productive level over time, and constrain the system enough so people feel held but not too tightly; and a willingness to hold loosely enough to allow for emergence of new ways of working required to make progress on adaptive work.

Exercising leadership to do adaptive work means disappointing people’s expectations that things will stay the same at a rate they can tolerate, without them ignoring you, trying to silence you, or resist you in infinitely creative ways. Leading in this way means trying things, observing what happens as a result, and trying again.

What People Won’t Tell You, Their Behavior Will Reveal

Energy, tension, and stress are necessary for progress. People need the right amount of tension—a productive range of tension and energy (not too much or too little)—so they can engage in and own their work. A productive amount of tension helps build their confidence and sense of effectiveness. An upper limit of tension (limit of tolerance) exists, above which an individual does not function well relative to the work at hand and begins to behave in ways that reveal distress. Similarly, there is a lower limit (threshold of learning), below which an individual does not function well relative to the work at hand and begins to behave in ways that reveal that.

If tension is too high, people feel overwhelmed. If tension is too low, people feel apathetic and unengaged. When people are within the productive range of tension, they can work with optimum creativity. The challenge in leading adaptive change is to keep oneself and others in the productive zone of tension as much as possible over time and create a culture of respect and honest dialogue that helps widen that zone. People’s behavior will tell you when they are out of the productive range. Your leadership work is to learn to read that behavior, and be willing to try, fail, and try again to help get them back into a productive range so progress can be made.

When the work at hand is adaptive, resistance shows up when people are overwhelmed with work (above the productive range of tension) or disengaged from work (below the productive range of tension). Behaviors suggesting someone is outside the productive zone include displacing responsibility (attacking the authority, blaming others, scapegoating the messenger), distracting attention (pretending to be busy, making the problem too big to solve, changing the subject), and denial (“This isn’t my problem.”)

Start by Lowering the Heat to Bring People Back into the Work

The challenge in the exercise of leadership is that the behavior looks the same above the productive zone and below the productive zone. Heifetz uses the metaphor of heat: when the person is above their limit of tolerance relative to the work at hand, the heat is too high and the behaviors of displacing responsibility, distracting attention, and/or denial show up. When the person is below the threshold of learning (below the productive zone), the heat is too low and the same behaviors show up.

When work avoidance (resistance) shows up, it is a signal that you are losing influence. A person exercising AL must then decide what to try next to bring the person back into productive engagement with the work. It is critical to understand that either situation can result in identical avoidance behaviors. Our usual assumption is that resistance means people don’t care and need to be pushed harder. In reality, this usually makes things worse; in healthcare, it is a safe bet that, for most people, the heat is way too high and their resistance means they are seriously overwhelmed.

When exercising leadership, learn to read work avoidance as a sign you need to try something to bring people back into the work. When you meet resistance, try lowering the heat first by validating the difficulty of the situation or by simplifying and clarifying the work. Break the work into steps or provide or resources like your attention, time, or training. At first, it can seem like lowering the heat means taking somebody off the hook, but you are actually trying to help put them back in the game. Try it the next time you meet resistance. Most of the resistance you see means the heat is too high. Lowering the heat is compassionate, builds relationships, and gets results. In exercising leadership to make progress on adaptive problems, a person must be able to step back, stop the action for a moment, and assess what is taking place. Leaders must open themselves to multiple possibilities, widen their set of diagnostic options, test their interpretations, take action, and reflect on the results of their tests of change.

In this breakout session, we will review and apply the fundamental principles and practices of AL to build your resources for transformation. Applying these ideas can enhance your ability to effectively work with others by seeing human behavior differently and making sense of the behaviors triggered by rapid, high-volume change. Through genuine engagement and transparent (yet accountable) decision-making processes, you can guide and drive the changes critical to your organization’s success.


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