Insights (Essays) January 2013

Conditions Leaders Influence

Hugh MacLeod and Maura Davies


I am back on the balcony of reflection. This time I am joined by Maura Davies, a leader currently in the midst of significant healthcare transformation. As we witness the churn of the healthcare system below we begin asking, what do healthcare patients, clients, residents need, and how can the system organize itself to respond? While the question is simple, the issues that need to be addressed are rather complex.

Most healthcare executives, managers, professionals and frontline staff developed their careers in a silo centered, bureaucratic model of healthcare delivery, often driven by the provider’s control of health services - not the patient’s perception of need. In command and control hierarchies, behavior is often honed to enable survival of the most political. Going forward, we need to focus on the entire system, the continuum, and focus away from isolated silos of activity. At the same time, we must also learn to tolerate far greater levels of ambiguity, as the system continues to evolve to meet the needs of those we serve. We also need to ensure greater personal responsibility to get the job done right. All of these changes will only take place if they are rounded in explicit shared values.

Suddenly the Ghost of Healthcare Despair appears and once again with an annoying disparaging smile shouted:

“Idealists! My robes continue to be updated with reports and briefing notes. My power continues to grow because each and every document contains a moment of genuine insight never acted upon! Ha,ha,ha! I have quite a wardrobe. Shouldn’t you be embarrassed to discover that the unconnected, competitive, evaluative, powerless pattern of experience among members of the management group is the same pattern of experience existing among members of management groups throughout the world? You spend far too much time on trying to fix one another rather than working together to master the conditions which influence you. Human nature dictates looking after self, we are not wired to work together, we are wired to compete. My robes are getting heavy.”

Unfortunately, our healthcare system in many respects still holds onto our traditional command and control systems, structures, and processes - where “accountability”, is often about “who is to blame.” Real accountability is about keeping agreements and performing jobs in a respectful atmosphere. It is about learning, truth, change and growth. It is not about fear and punishment. We need to learn from our “best mistakes” and continuously improve the system of which we assume stewardship.

Before Ieaders can see the future state as a vivid visual image, we have to get to know and understand the underlying values, beliefs and attitudes held by current stakeholders. The old expression “you cannot see the forest for the trees” must take on a new meaning. Leaders need to see the trees, not to mention the spaces between the trees and the surrounding flora and fauna. To get “out of the box”, Ieaders must admit to themselves that they do not have all the “answers” and to be successful, have to ask the right “questions.”

The only way leaders can truly understand the current state is to go to the “gemba”, the equivalent of our “factory floor” where real value is produced. Unfortunately, we have created roles and ways of working that currently result in many leaders spending most of their time in their offices and meeting rooms. When leaders are not at meetings they are trying to keep on top of the hundreds of emails that bombard them every day.

What would happen if we changed this picture? What if leaders spent most of their time talking to patients, families and staff where care and services are actually produced? Some organizations, especially those adopting lean management systems, are doing this and finding it dramatically changes their understanding of how the system works and needs to change. It also puts the power and responsibility for continuous improvement in the hands of those who actually deliver care and services, changing the role of leaders to being coaches and supporters for point of care staff.

This may sound obvious, perhaps even overly simplistic. Why haven’t we done this already? Frankly, it is a radical change for most leaders and organizations. It is a big transformation for leaders to transition from being knowledge experts conveying the wisdom of their many years’ experience to becoming visible, present leaders whose greatest skill is asking the right questions. Many leaders would confess they are not comfortable being close to the point of care for which they are ultimately responsible. When is the last time the CEO put on greens and spent time in an operating room? When did the director for home care actually accompany a community therapist in a home visit in the inner city? When did the vice president responsible for materials management spend time in the warehouse understanding that process? How often do leaders spend time in areas that are not their direct responsibility or participate in quality improvement initiatives outside their personal portfolio?

The questions leaders ask give a powerful signal about what is really important. Asking the right questions also breaks the ritual conversations that take place. Leaders must ask the right questions at the right time. A key is in framing of the question, the timing of its asking, in a manner that creates commitment to learning how to continuously learn and improve. And guess what we will learn, “all the information required is always present within the system spaces.”

And what about values, those deep-seated, fundamental beliefs that guide the motivators of human behavior? Values must be a foundation of our emergent healthcare system culture. If employees value caring, collaboration, and human potential, then they will act more effectively as teams, and be motivated to work together to improve services to the public. If they value money, prestige and power more than caring collaboration and human potential then the healthcare system will splinter into power groups and internal competition. It will be the leaders who make meaning of those values, by talking and acting consistently with them. It will be through their modelling of appropriate behavior, which values indeed dominate in the healthcare organization.

Simply put, its soft things like; organizational culture, teachable moments, effective people collaboration, ability to experience change and learning at the rate needed to create breakthroughs that create all the problems with the hard things like: healthcare consumer satisfaction, crisis frequency, retention of staff, cost of performance and cost of service. Leaders must take responsibility for the soft and hard reality they create.

To achieve the vision for healthcare, leaders from all parts of our system need to come together not to manage the change or to just cope with it, but to use it to create a powerful vision that builds the kind of healthcare delivery model we wish to see. Leaders in this environment will be continuous learners who share an intuitive, emotional, personal identity with healthcare. It was through such human resolve that healthcare institutions came about; it will be through human resolve that they will change. We may not have all the answers but if we have the right balance of vision, values, courage, reality and ethics we can begin a transformational journey. Our future depends on it. 

We must also have the courage to identify and change the incentive systems that encourage and reward behaviours that run counter to the customer-centered team-based environment we all say we want. This requires tough conversations and in some cases a significant change in the traditional power gradients that currently exist. The simple act of literally “putting the patient in the room” has an amazing impact on many conversations and reveals the underlying differences in value systems we experience but seldom acknowledge.

In closing, whatever relationship challenges you face, as solid and as personal as they seemed to be systemic, they may have less to do with the personal characteristics than with the “conditions” of the space that people are sharing.

We must continually ask how can we as leaders meaningfully tap into and create a culture that encourages the expression of the intellect, passion, commitment and experience of frontline staff to make real changes that satisfy healthcare consumer needs and expectations. Excellence in healthcare services will result from employees’ pride in the work they do. We will get to a future state through clarity of purpose, alignment of effort, credibility of leadership, integrity in organization and accountability for performance.

To quote Peter Senge… “By coming together in open and honest dialogue, we can integrate our fragmented, individual perceptions of reality into a more complete and accurate representation of our current circumstances, our true shared reality.”

Next Week’s Guest on the Balcony of Personal Reflection: J. Davidson in a conversation titled “Fragmentation vs Collaboration”. 

Click here to see the First Series of Ghost Busting essays.


Click here to see essays from the Second Series: The Ghost of Healthcare Consciousness.

About the Author

Hugh MacLeod is CEO Canadian Patient Safety Institute Maura Davies is President and CEO Saskatoon Health


 Senge P. The Fifth Discipline. Doubleday, New York. 2006




Jennifer Jilks wrote:

Posted 2013/07/02 at 08:58 AM EDT

Truthfully, top down change will not work unless all believe in treating patients with respect. That is what it boils down to, and those who cannot or will not treat patients this way must be reported, and either disciplined or terminated.


You must sign in to comment Sign In or Create an Account to add comments


Related Content

Nursing Leadership

The Role of Education in Developing Leadership in Nurses



Healthcare Quality Improvement Requires Many Approaches


Nursing Leadership

Harnessing Our Collective Voice: Highlights and Reflections from the 1st Annual National Nursing Executives Summit