5 Principles of Adaptive Leadership and Why It’s a Critical Skill for Healthcare Leaders

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Editor’s note: This mini lesson represents some of the content presented at Health Catalyst University’s Accelerated Practices (AP) Program. With the purpose of educating health professionals, the AP Program prepares healthcare teams to accelerate outcomes improvement. Faculty and guest experts of the program are recognized leaders in their respective fields of expertise. Below, Val Ulstad, MD, guest expert for Health Catalyst’s Accelerated Practices (AP) Program, shares insight about the need for healthcare leaders to practice adaptive leadership as a way to facilitate and manage organizational change—a topic she covers in her session on adaptive leadership.

You’re a person trying to make things better in the healthcare industry. 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 means: mobilizing others to make progress addressing the gap between the way things currently are and the desired state you are striving toward.

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.

In this tumultuous era of new reimbursement and care models—where there are many uncertainties and the changes are numerous and complex—adaptive leadership is a way of seeing the human condition and understanding what is needed to work with others. These are skills every healthcare leader needs to be successful.

Why Adaptive Leadership for Healthcare Leaders?

Adaptive Leadership is a leadership language and conceptual framework that Heifetz developed to help organizations 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.

Heifetz used his living laboratory, the Mid-Career Master of Public Administration Program at the Harvard Kennedy School, to develop this language and approach. Harvard Kennedy School is a school of public service that attracts professionals from around the world to learn and reflect on their work in the world. Here is where I met and studied with Heifetz and where I 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 adaptive leadership, 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. Most recently, I’ve begun teaching Heifetz’s Adaptive Leadership framework for Health Catalyst’s Accelerated Practices (AP) Program.

5 Principles of Adaptive Leadership

The following five ideas form the framework for adaptive leadership. Understanding these principles will help you on your journey to becoming an adaptive leader.

  1. There are two types of challenges: technical and adaptive.

With technical work, the answer to the problem is already known and just needs to be applied. Take, for example, a patient who is having a heart attack. He arrives at the emergency department (ED) with squeezing chest pain. An EKG shows ongoing injury. The diagnosis is recognized, and resources are quickly mobilized to get the patient to the cath lab where they perform a diagnostic angiogram that shows a clot in his coronary artery. The artery is mechanically opened and a stent is placed in the blocked artery to restore blood flow and abort the ischemia. The process is predictable: there are clear steps and actions to be taken, and each person’s expertise is applied to serve the patient efficiently and effectively. These critical steps represent the necessary technical work for this patient’s care, aimed at restoring coronary blood flow so deeper issues can be addressed.

As the patient recovers, his healthcare team must help him do a different kind of work: adaptive work. The patient needs to realize what just happened: he is mortal; death is not optional (an all too common cultural belief). He just had a near miss, and it’s up to him to care for himself differently if he wants to live a longer and healthier life. The stent alone will not guarantee longevity. He needs to change his understanding of and how he approaches his life to have the best chance of preventing another heart attack. He needs to stop smoking, lose weight, get his lipids and blood pressure under control, address any mental health challenges, and take his new medications. The patient’s mind and his metaphorical heart—his beliefs and his emotions associated with those beliefs—need to change in order for his behavior to change and his physical heart to continue to heal. This is hard work—this is adaptive work, and his healthcare team’s skill at facilitating his adaptive change is critically important.

Budgets are another example. 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 improvement is adaptive work.

Here are the characteristics of adaptive work:

  • There is a gap between the way things are and the desired state.
  • There are multiple perspectives on the issue.
  • New learning needs to happen.
  • Behaviors and attitudes need to change.
  • Old ways need to change, creating a sense of loss.
  • People with the problems are key to solving the problems.
  • Resistance is triggered in stakeholders.
  • It takes longer than technical work.

Something to take note of: the most common cause of leadership failure is treating an adaptive problem with a technical fix. We do it all the time in healthcare. Technical work is not bad or unimportant; it is just insufficient to address adaptive challenges.

  1. People need a certain amount of tension to do their best work, but the amount of tension needs to be productive.

People need the right amount of tension—not too much or too little—so they can engage in and own their work. This helps them build their confidence and sense of effectiveness. If tension is too high, people feel overwhelmed. If tension is too low, people are unengaged. When people are in the productive zone of tension, they can work in their optimum zone of 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.

  1. There is a difference between the role of authority and the exercise of leadership.

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

Influence must be used constructively, and developing constructive influence requires the following: assessing the other person’s capability to actually do what you’re asking of them; helping the other person see what’s in it for them; earning their trust; speaking to and understanding their perception of cost (such as their time and energy); and acknowledging their perception of the risk of following you (e.g., worrying about their status with their peers or fear of what you will ask next).

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 also means trying things, really seeing what happens as a result, and then trying again.

  1. Work avoidance (resistance) means that people are outside the productive range of tension.

When the work at hand is adaptive change, avoidance can show up if people are overwhelmed with (above the productive range) or disengaged from work (below the productive range). 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”).

work avoidanceExamples of work avoidance

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 behavior of displacing responsibility, distracting attention, and/or denial shows up. When the person is below the threshold of learning, or 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. An adaptive leader must then decide what to try 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. The usual assumption is that resistance means people don’t care and need to be pushed harder. In reality, this usually makes things worse, since 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 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 restore resources like your attention, time, or training. At first, it can seem like lowering the heat means taking somebody off the hook, when in fact, you are trying to help put them back in the game. Try it the next time you meet resistance. Most of the resistance you will see means the heat is too high. Lowering the heat is compassionate, builds relationships, and gets results.

  1. Reflect in action by spending time on the balcony and the dance floor.

Heifetz and Linsky use the analogy “reflect in action by spending time on the balcony and the dance floor”to illustrate how leaders need to metaphorically step away (head up to the balcony) while in the midst of their daily work (the dance floor). This enables leaders to gain a different perspective and gather insight, not only on issues but also on their own behaviors and beliefs.

If leaders stay overfocused on their operational work (on the dance floor) without seeing the issues and themselves as part of the big picture (from the balcony), they may lose sight of the big picture, forget what the work actually is, and exhaust themselves with busyness. But staying “on the balcony” too long may result in others viewing the leader as disengaged, irrelevant, or manipulative.

Optimal “time on the balcony” allows a leader to see patterns, re-evaluate assumptions, and make novel connections. Optimal engagement “on the dance floor” builds credibility, allows a leader to see and feel what those on the front line experience, and understand what the work is asking of their people. Both perspectives are necessary, and adaptive leaders must learn to do both.

It is likely that at times you already exercise this ability. For example, have you ever presented to a group and felt it wasn’t going well? This is a case of spending time in the balcony (gauging where others are at) and being on the dance floor (giving the presentation).

An Effective Leadership Style to Achieve the Triple Aim

Achieving the Triple Aim is a challenge everyone in healthcare is facing. But with challenges also come opportunities. One opportunity is the chance for leaders to embrace adaptive leadership. Exercising adaptive leadership will help leaders mobilize workers in an era of great change and uncertainty to make progress addressing the gap between the way things are and the way we would like them to be.

Adaptive leadership is anything but a command and control type of style. Instead, it’s a powerful framework that helps leaders see human behavior differently, make sense of the behaviors triggered by rapid high volume change, and a way to genuinely guide and drive the changes critical to your organization’s success—and to achieve the Triple Aim.

Key Takeaways:

There are five principles that form the framework for adaptive leadership:

  1. There are two types of challenges: technical and adaptive.
  2. People need a certain amount of tension to do their best work, but the amount of tension needs to be productive.
  3. There is a difference between the role of authority and the exercise of leadership.
  4. Work avoidance (resistance) means that people are outside the productive range of tension.
  5. Reflect in action by spending time on the balcony and the dance floor.

Characteristics of adaptive work include the following:

  • There is a gap between the way things are and the desired state.
  • There are multiple perspectives on the issue.
  • New learning needs to happen.
  • Behaviors and attitudes need to change.
  • Old ways need to change, creating a sense of loss.
  • People with the problems are key to solving the problems.
  • Resistance is triggered in stakeholders.
  • It takes longer than technical work.

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