Insights (Essays) February 2013

Passive Following vs Future Focused Leading

Hugh Macleod and Graham Dickson


Today on the balcony I am joined by Graham Dickson who has dedicated his career to leadership studies. How often in recent weeks have we heard one or more of these messages?

  • There’s too much uncertainty, the healthcare agenda keeps changing.
  • Let’s keep our heads down.
  • Now is not the time to be out front.
  • Let them go first and we’ll see what happens.
  • What does government want? This too shall pass.
  • Let’s just wait it out.
  • We need more regulation and legislation.
  • This is what the government wants — this is how we’ll be evaluated — feed them what they want.
  • Hurry up. Go fast. Stop

We pull research levers and are surprised by the lack of traction and take-up. We pull economic levers and are surprised by their unexpected effects on health and/or the operational environment. We pull healthcare levers and are shocked to witness spiraling and unsustainable costs. This kind of blinkered thinking is something we can no longer afford. More importantly, it does not create added value.

Yes, the healthcare system is large and complex and is inherently prone to inertia. Overcoming it would be a challenge even if Canadian healthcare were less conservative, more information rich and less structurally fragmented. It is all too easy to revisit the same issues, engage in the same conversations and appeal for money as the solution to all problems. Then we hope that repetition will lead to a fundamentally different result.

Most challenges in human systems can’t be solved with a quick technical fix. Even so, healthcare people usually want such a thing. Leaders, eager to please, respond accordingly by taking the problem on their shoulders and developing solutions that might alleviate a symptom, but not the underlying problem. A major pitfall of leadership is assuming that you’re the one who must come up with the answers, instead of developing adaptive capacity, the capacity of people, to face root cause problems and take responsibility for them. Change requires more than identifying the problem and then a call to action. It requires looking beyond the problem and finding the source of trouble. The real problem is frequently located where we would least expect to find it – inside ourselves. Yet those aren’t the only opinions we will hear today. As usual in these haunts, a visitor speaks up from the shadows, the Ghost of Healthcare Despair.

“Healthcare today is all about following and playing it safe. Give your heads a shake. Big and small politics rule the day. When things go wrong, as they always will, you see knee-jerk reaction. Punish all because of the behaviour of a few. Of course, then you live with the law of unintended policy and regulatory consequences. Your healthcare dance floor chaos in motion with weak clarity of purpose and alignment of effort. Survival for your type is always about playing it safe — creativity and innovation be damned.”

How do you develop the courage and willingness to take a risk, create conflict and put truth on the table? Especially in a risk intolerant environment with a history of playing it safe? Let’s take a close look at the healthcare system. Boy, this balcony is high…we can barely see the people on the healthcare dance floor.  And the stairs to get here, they were tough to climb; we’re somewhat weary.  Let’s sit down for a few minutes to contemplate our thought.  We are comfortable here, if we ignore the media and keep the music turned down.

It would be good to hear what the people on the dance floor have to say about the healthcare dance challenge.  There is no way we’re going down there again and then back up here again.  The steps are too steep and there are way too many of them. To get here on the balcony demands a lot of physical exercise. Besides, we were not sure we could really hear them anyway unless we went down a number of times. Those young people: given the vigorousness of their dancing, would simply jostle us from pillar to post.

Maybe we’ll just observe a bit and see if something is going wrong, and if it is, we’ll yell from here. Wow.  They are really good at mastering the dance steps of the waltz.  It looks like they have been practicing for months!  Look at that group over there…beautiful footwork. Whoa.  The music’s changed!  Now it’s a tango!  Looks like lots of confusion down there.  Obviously some couples know the tango, but a lot don’t. Look at that lovely couple who really know the moves just bowled another couple still doing the waltz (beautifully, we might add) over!  Guess they didn’t hear the music change.

Thanks!...where do you turn it on?  Oh, yeah…ewww, loud feedback—just like nails on a chalkboard! Well, that got their attention.  Everyone stopped in mid-stride, although the music kept playing.  Hey, the man in the checked shirt partnered with the woman in the culottes…your supposed to be tangoing.  Why are you waltzing?  What?  Yelling louder, it is clear we can’t be heard over the music.  Can someone down there give them a megaphone too?  No!  Battery’s dead? Someone on the floor yells, we are not used to talking to people who sit on the balcony!

The music’s changed again.  It’s now a cha cha.  Now we see couples doing waltzes, tangos and cha chas at the same time! Although most still seem most comfortable with the waltz. This is fascinating. We see the dance instructors trying to group them and help them change.  Look someone is taking the dance instructors off the floor.  Now there is real confusion.  No one seems to know what they should be dancing to. What is that those couples are doing?  Some are leaving!  The music is getting faster and faster…what is that?  Jazz?  Rock and Roll, Improvision? 

Now the dance instructors are just sitting down on the floor…or off to the side, throwing their hands in the air.  Look at that couple over there…they’re just chatting with some of their friends.  That couple is doing something that might be called a dance….There is chaos down there! 

Didn’t they outline all these dance steps in strategic dance plans?  Didn’t they all get the plan explained to them by their dance instructor?  Do they have enough instructors?  Looks like some of the dancers are professional at some dances, but refuse to learn others?  And some are good at one, and not the others?  And it also look like a few of the dance instructors actually have not taken dance, or know anything about dance instruction?  Why didn’t they take the initiative to learn about the new dances?

We yell down…Stop the music!  Stop the music! 

We can’t!  Why can’t we? The patients and the politicians are playing the music  and they can play what they want.  Maybe we’ll just stay up here, sit in the corner, and get our breath. Sure hope when we peek over again that everyone will have organized themselves, and that the dance instructors will find some energy to do their job.

It is comfortable on this couch over in the corner away from the music.  Let’s talk about this. What we saw was chaos.  Is it always like this on the healthcare dance floor?  It just seems like no one’s in charge. Who indeed is leading?  And who is following?

Seems like the people on the floor, doing the waltz, knew who was leading and who was following, as long as they knew the dance they were supposed to be doing, and as long as they recognized the music and the dance steps to go with it.  But change the music, and a lot of them got confused or resistant, if they were really enjoying their dance.  Without knowledge of the steps and how they fit the music, neither knew who should lead or follow…, and if it wasn’t satisfying, they wouldn’t change either.

Somehow we thought if we did a strategic dance plan, and if people read it, they’d be able to dance to the changing music.  That was our leadership model.  But they didn’t follow.  We wonder why?  Some did…some (a very few) took initiative and led themselves.  But most simply ‘followed’ what they have been trained to do and what they are good at.  Why is that?  Maybe we should be teaching initiative.

Executive directors were supposed to teach the strategic dance plan to the dance instructors. The dance instructors were supposed to teach the strategic dance plan to the dancers. After all, they’re our ‘on the floor’ leaders.  But obviously they didn’t and couldn’t.  Is it because they haven’t had time to learn how to instruct, or they don’t know all of the dances themselves? Did they take the initiative to actually develop a plan to do so?  Some of them have 100’s of dancers to teach?  How was that ever supposed to work?

Why didn’t anyone take the initiative to tell us on the balcony?  Oh yeah…the battery in the megaphone was dead. And some of them did, but we didn’t listen?  How does that happen…oh.  The on line dialogue around the plan…we did hear about some of that--some dancers asked if we would come down from the balcony and dance with them to see what it was like.  WE must admit we forgot…and besides, those stairs are steep…and we need our perspective to make sense of everything; they’re just too close to it.

It sure didn’t help when they had to pull a bunch of the dance instructors out. No wonder when the music sped up and we expected them to exercise the leadership to take control of the chaos, the remainder just gave up and sat on the floor. Why didn’t folks resist those cuts?  Well you know, it’s a lot easier just to follow and make the best of it. From what we just saw, there is no best of it!

How did we ever allow the music to be controlled by the customers? We are here to dance to their tune?  When did that change?  That kind of changes the dance dynamic.  Maybe we should have some way of organizing that a little better…or teaching ourselves to be more flexible in response to the family, patient, resident, and client voice.

Those steps are high, long and steep.  It’s comfortable on the balcony…a lot quieter.  Hmmm…there maybe something in this initiative thing. We’ve mentioned it a lot.  We wonder indeed if leadership is a function of our collective initiative…and followership is simply being passive.  We wonder how that happened.  This is worth some more thought and reflection with the next guests on the “balcony of personal reflection”.

Next Week’s Guest – On Balcony of Personal Reflection: Dr. D. Cochrane in a conversation titled “ Danger of Simplification”. 

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

H. Macleod is CEO of Canadian Patient Safety Institute. G. Dickson is Royal Roads University Professor Emeritus-Leadership Studies and co-creator of LEADS-Framework.


MacLeod H. A Call For New ConnectivityLongwoods HealthcarePapers. 2011. 11(2)




Rob Robson wrote:

Posted 2013/02/22 at 01:03 PM EST

Some very interesting metaphors - the balcony one may possibly accurately describe how some healthcare leaders feel and act. And the dance floor metaphor is an interesting way to introduce the concept of complexity. But then the important points are lost - when you say "healthcare is large and complex" you are bang on in your description. Unfortunately you then add that healthcare is "inherently prone to inertia". In fact the opposite is true. Most complex adaptive systems are constantly adapting and changing as the external environment changes. This is happening whether we acknowledge it or not and complex systems self-organize whether we understand or attempt to understand and influence the processes that lead to the emergence of new patterns and relationships within a complex adaptive system. Our "rules" cannot be imposed on the self-organization processes - it doesn't matter how many dance instructors there are or how well prepared they are if the processes they are "teaching" are imposed from the "balcony". To explore this further visit One final extremely important point - the "music is [definitely not] controlled by the customers". You are probably right that "politicians are playing the music" but when it comes to patients, we have all been spectacularly tone-deaf for decades. For the few courageous patients who try to compose music we definitely cannot hear the tunes or understand the stories they contain.


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