For these reflections, each leader selected a few lessons from the many they have learned. Each chosen lesson for each leader has its own history. Each lesson has emerged from the experience of these thoughtful, practicing change leaders. We can think of the collection of lessons as a "tapestry" of change and change-making in health care. As we examine the tapestry more carefully I think it is possible to see some of the threads that help hold it together. Let me try to briefly describe each of the threads I have seen—not as a summary or homogenization of the lessons, but as a way of inviting further inquiry into, around and underneath them.

What Matters

Let's name the first thread What Matters. Its name comes from the realization that all of these lessons derive their significance from the question that is most important about leading change in healthcare: how has the patient or population of patients been affected by the changes that have been designed and made? This singularity of focus informs the work and the improvement – the changing – of healthcare. It involves a deep understanding of those who benefit from healthcare. It requires knowledge of how illness is a burden in the lives of those served. It entails an understanding of what the patient or population of patients is trying to accomplish by the receipt of healthcare, sometimes described as knowing the "job that the customer is trying to do" (Christensen 2009: 10). It concerns the care for an individual and for a population of individuals. It forms the litmus test of any effort to change and improve healthcare.

Notes to Self

The second thread, Notes to Self, arises from these leaders' own reflection on their experiences. The crucibles of their experience that have allowed their leadership competencies to emerge gave rise to the lessons, in part because these leaders have made some space in which to notice them (Bennis 2007). Through reflection, they build upon these experiences and create the "common wisdom" of leadership for themselves. The key, however, is the process of inquiry and reflection – not the specific items that may have emerged from the reflective process.

The process of inquiry and reflection is part of the radical recognition of the present context as change leaders aim for and work to create a future context. By honest reflection about the present, change leaders realize that what was needed to get here is only part of what will be necessary for getting to the future, there.

It starts with clarity about who they are trying to be, as Tom Lee suggests: "Choose whether you want to be a critic or a playwright." Many have noted that, for leaders, "making things happen" is fundamental, and they have learned that usually requires a commitment to getting action started and persistence. They have recognized that aligning the work of change with the intended future of an organization can invite the synergies that come from common work.

They model – even as they advocate – the importance of learning from the situations they face. They know the benefit of multiple knowledge systems as they continue to search for both the what and the how of the changes they seek, as Harlan Krumholz observes.

They note that opportunities emerge in many ways and that their own efforts to frame or re-frame situations can be very helpful. They have learned the importance of "going to Gemba," the Japanese aphorism advising leaders to recognize the place where actual value is created in the workplace; physically showing up there allows leaders to gain detailed insight into the "heart of the work" (Imai 1997). They understand that by testing and experimenting with these discovered opportunities, they can contribute to the vitality of the ongoing work.

In short, these leaders have learned to balance inquiry and action and understand the practical utility of reflecting on and in their practice as leaders (Schön 1983). They realize that all leadership practice is practice.

About Others

The name of the third thread is About Others. Underpinning this thread is real curiosity about human behavior.

These leaders have recognized that little in healthcare happens as a result of one person acting completely alone, so they have learned to explicitly invite others to the shared work. They know that, in doing so, they benefit from the synergy of good teamwork, from the wisdom of different viewpoints and from the joy that comes from real partnership in work. At the same time, they know that conflict is the flip side of cooperation. Learning to learn from conflict allows the leader to harvest the wisdom of diversity.

Good work with others is built on the foundations of trust and respect, recognizing the truth of Paul O'Neill's (2001: xiii) propositions about organizations with the capacity for greatness. Trust and respect make it possible to answer "yes" to the following:

  1. "I'm treated with dignity and respect everyday by everyone I encounter … and it doesn't have anything to do with hierarchy."
  2. "I'm given the things I need to make a contribution that gives meaning to my life."
  3. "Someone noticed that I did it."

Good Data

The fourth thread is about information, Good Data. These leaders know that the important "language" of topics such as news, accountability, science, opportunity, effectiveness, outcomes and satisfaction are the quantitative and qualitative data that enter their life in a day. Whether the data they receive come in the form of numbers or words, they must pass the tests of validity and reliability. The data must faithfully reflect the phenomena under consideration. Errors in gathering and analyzing the information precede mistakes in its use. These leaders know that good data are their friend and bad data are their nemesis. Transporting and storing data are quicker and cheaper than ever before, but to use data well in the improvement of care requires attention to the basics of defining, gathering and analyzing information over time. They know how challenging it is to remain open to potentially disconfirming data – information that is contrary to what you expect or hope. They have learned to seek, use and require good data.

Getting Time Right

The last thread in this tapestry of lessons is Getting Time Right. For leaders, this involves understanding the past, the present and a view of the future that allows them to make sense of the situation they are facing. Two helpful perspectives are found in the ancient Greek ways of thinking about time: one about the future and one about the present.

Ancient Greeks viewed the future as "something that came upon them from behind their backs with the past receding away before their eyes" (Pirsig 2005: 424). The trends in demography, technology, information, law, education, economy and science become the inexorable forces at our backs creating the future. Together and separately they are forming new realities that may or may not respect the "categories" that we have made from our past experiences and that occupy and fill our current views of the situation (Schwartz 1991). Holding our personal categories lightly enough to recognize and enable the future that is forming can be challenging.

The second perspective is from Greek mythology and involves thinking about the idea of time in the present. It noted two kinds of present time: chronos and kairos. Chronos time is the familiar linear, horizontal, clock-measured, calendar time. The word comes from the god named Kronos, who, with his sister, Rhea, fathered many children. Their early offspring were named Doom, Fate, Death, Dream-Troubled Sleep, Blame, Grief, Nemesis, Deception, Old Age and Discord. The other kind of present time was personified as Kairos, the god of opportunity, a man with wings on his shoulders and heels, and scales balanced on a knife edge, who carried the Wheel of Fortune. Kairos time is "opportunity time." It is when meaning inserts itself as a significant "moment" in the midst of our daily lives. Kairos time does not respect the constraints of chronos time. If chronos time is horizontal and sequential, kairos time is vertical and non-sequential (Eberle 2003: 55–56).

These ideas are put into use when these leaders respect the fallacy of projecting the current situation forward in a simple linear way; they recognize the importance of discerning the vertical kairos moments in which opportunity, meaning and sense-making live. These understandings of the past, present and future allow access to the deep sources of energy in any workforce, and in the leaders themselves.

Another aspect of getting time right has to do with understanding the importance of timeliness – of delivering a service or intervention in a timely relationship to the need. Paying attention to the reality that many things leaders do are really never done – only due. Timely communication respects the world of rapid information movement and the expectations of the leaders by those led. Timely communication is grounded in a deep respect for the others involved as leaders give attention to the cycle times needed in the actual closure of communication loops.

Getting time right also involves having the time to do what is important. We all have the same number of hours in a day, but we differ in how we choose to "segment" that time (Heschel 1951). Our values inform the way we divide up our time into days, weeks and years. The lessons of these leaders reflect a commitment to segmenting time so that they can put their efforts on important relationships and meaningful work. Recognition of time desired and made available for family and friends, for example, informs the way we choose to divide our time. Focus is related to an underlying set of values about the calendar and the work that needs to be done. Accessibility is related to the time-segmenting choices leaders make about the value of access to them by others. A "full" calendar is not the same as a "helpful" one that enables the faithful, fruitful and responsive expression of people who are leaders. Good leaders know the importance of avoiding the frenzy that comes from trying to help everyone with everything (Merton 1965: 86).

Lastly, getting time right helps all leaders recognize they only get a "turn" in their jobs (de Geus 1997). Planning for the next in line – succession – involves the work of developing the path for those after you. Attending to succession is the corollary to knowing that what you've been working on is not only big enough to be a worthy social goal, it is more than one person can accomplish in life. In this frame, succession planning and attracting and developing those "next in line" are a source of joy – not an optional burden or responsibility – that emerges when leaders get time right.

Getting time right involves understanding the important work, those who are needed to get the work done and how they will gain access to you, the role of the past, the nature of the present and the ways in which the future emerges, the horizontal and vertical dimensions of time and the sense of mastery that comes from aligning your values with the ways you segment your time. More than just a cognitive understanding, for leaders it means living and acting in accord with that understanding.

The threads that help hold these lessons together are interesting in themselves, but when woven together with the lessons and the stories about how they were learned and the life experiences of those involved, they create an inviting tapestry.

The Way It Is
There's a thread you follow. It goes among
things that change. But it doesn't change.
People wonder about what you are pursuing.
You have to explain about the thread.
But it is hard for others to see.
While you hold it you can't get lost.
Tragedies happen; people get hurt
or die; and you suffer and get old.
Nothing you do can stop time's unfolding.
You don't ever let go of the thread.

Credit: William Stafford, "The Way It Is" from The Way It Is: New and Selected Poems. Copyright © 1998 by the Estate of William Stafford. Reprinted with the permission of Graywolf Press, Minneapolis, Minnesota,

About the Author

Paul Batalden, MD, Director, Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice

Program Director, Leadership Preventive Medicine Residency Program, Dartmouth-Hitchcock Medical Center

Professor of Pediatrics, Department of Community and Family Medicine, Dartmouth Medical School


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