Insights (Essays)

Insights (Essays) May 2013

Strategy and Its Interplays

Hugh MacLeod and John Abbott


Today on the balcony my guest is John Abbott, a leader with a national mandate. The formation of strategy is an interplay of craft and art, experience and insight, learning and visioning. It is a synthesis, if you will. The heart of the strategy formation process can be found in learning from tangible experiences and visioning from creative insights. It lies, if you like, in the answer to two questions: 1) How to get into the mind of the strategist? and 2) How to read the mind of the organization? Our discussion is barely under way when we are cut off by an old acquaintance – the critic, the Ghost of Healthcare Despair:

“What were once hard variables are increasingly seen as abstract and secondary,” shouts the Ghost. “Soft variables – intentions, interpretations and relationships – are increasingly considered part of the more concrete and primary sphere of value creation. “Hence, the core of what is considered real has moved from the more tangible to the more intangible variables of social behaviour and managerial action. Leaders, in order to do well, must pay attention to a different set of variables – variables such as intentions, interpretations and identity.”

One of our biggest challenges – and thus opportunities – is that we spend considerable time evaluating the evidence on the hard side of healthcare. Yet we do not spend enough time – if any time – evaluating the soft side of healthcare. Let’s illustrate what we mean. The culture of the healthcare system – relationship patterns, teachable moments, integrity between physicians, as well as between physicians and nurses – has a direct outcome on the hard side of the business: Crisis frequency, cost of doing business, patient safety incidents and quality outcomes.

Invite us into your institution. Allow us to do a walkabout. Within a second of arriving in a medical unit we will be able to feel one or two things. It might be: “It feels good here.” But let’s walk on to a different medical unit with the same patients, the same staff profiles, the same I.T. system, the same protocols, the same requisitions ... and we may feel: “It doesn’t feel so good.” And if we drill down on the differences between the two, we’ll find healthier relationships in the first example. We’ll also see lower costs because of reduced overtime. We’ll see lower staff turnover in nursing, thus fewer adverse events, higher quality care and improved customer service.

We do not make things in healthcare. We deliver services to people through teams of people. When the relationship patterns are healthy between the providers, magic happens. The “soft” impacts the “hard.” The ability to perceive and evaluate the tacit depths of an environment “within a second” is an empathetic skill. As healthcare continues to operate in a high-velocity context, leaders will have to develop their “blank canvas” capacity – their capacity to sense and go with what emerges from nothing. How do leaders deal with something emerging from nothing? They recognize that individuals, groups and institutions are subject to unconscious processes that support or limit their performance and evolution. To be a transitional leader you must evolve in consciousness, by making the unconscious conscious. Leaders need to recognize early that increasing consciousness in an individual, a team or a system creates the fuel for transformational change. The continuum of consciousness development across the healthcare system and the interconnection between “soft” and “hard” can be illustrated this way:

The above diagram depicts the ecology of overlapping, interpenetrating relational spheres. Leadership in healthcare may be defined as shaping “life enhancing” conditions. Such leadership is both deeply personal and inherently collective. It involves individuals tapping their sources of inspiration and imagination; it involves collectives actualizing emerging futures.

Traditional command and control styles of leadership have focused on having personal power and authority over others. This style of leadership has been reserved for a few key individuals whose role has been associated with behaviours of control, direction and “knowing what is best” for others. This approach to governance and management does not support an empowered, accountable and responsible workforce – the type of workforce that is necessary to build and maintain a flexible, innovative, dynamic and successful organization.

So, from where or how does this leadership emerge in healthcare in Canada? We begin by trusting people and encouraging them to bring new ideas forward, whether on the front lines of care, around the management team meetings or at the boardroom table. We listen to their ideas and ask the tough questions, rather than providing answers. We create a culture that allows the issues to be framed in a way that encourages people to think differently, rather than laying out a map of the future with all the directional signs incorporated. It means co-creating with people their new roles, power relationships and behaviours.

We need a framework or context to allow future leaders to emerge and current leaders to excel. That context can come in the form of a vision of what we want to achieve for Canada’s healthcare system. The Canada Health Act just doesn’t do it by itself anymore! That’s where today’s leadership is found wanting. Do we have today’s leaders able to say, with conviction, that their vision for healthcare says we will have the best healthcare system with the healthiest of populations in the world? Declaring this vision would leave no one in doubt as to what our leaders want to achieve. Just as we promote Canada internationally as having the best of financial systems, shouldn’t we want the same for our healthcare system, especially since we have all the requisites to be able to achieve this vision? 

The additional advantages for declaring a vision for Canada’s healthcare system is that it would focus our transformative efforts at every level of the system. It would distribute the leadership role throughout our system. At the same time, each organization, provider and ministry would have the responsibility of holding one another accountable for achieving this vision. Canadians, as patients and taxpayers, would have a direct role as well, by being more engaged and living healthier. It would also invite other sectors in society to participate in moving Canada toward a healthier society. To achieve this vision, we will need a “whole of society” approach to health.

Our health leaders cannot act alone or in cliques. A strategic approach to decision-making must be the mainstay of our leaders. It is easy to be bumped off course at every unknown and side tracked by every crisis. Leaders foresee these things or are adept at seeing their way through these ever-occurring events. Today’s leaders embrace social media, sift through the multi-forms of information with acumen and leverage new technologies – not as an end but as a means to improved care. They thrive on transparency, public reporting, and being held accountable for results. They bring to Canadians’ attention the importance of learning from the best performing systems wherever they are, whether in Europe, the US or across Canada. They move heaven and earth to ensure their systems identify and promote innovative practices to achieve the best in care. They encourage the bringing of clarity and evidence to the issues confronting their systems and open the pathways that allow solutions to emerge. In essence, our leaders are adaptive, imaginative, thoughtful but above all strategic, and who help identify and support the changes we know can work, source the resources needed for implementation and cheerlead the way to success.

There is a way forward for our healthcare system. It will require leaders who have cultivated a clear and specific direction for their piece of this everchanging, multi-faceted, multi-layered system supported by a strategic approach to implementation. They must lead with a personal commitment to change the status quo and bring a high level of determination to achieve results. Their success will ripple throughout and allow others to succeed. Like Canada did at the 2010 Winter Olympics in Vancouver, when, as a nation we set a goal, we were able to set aside the ghost of despair from previous Olympics, and achieved our collective aspiration for our athletes and country.

Now it is time to take this same bold approach to our healthcare system and bring to it a vision, adaptive leadership and dynamic strategies. Canada will be a better place for it.

It is reminiscent of an old metaphor: Drop a pebble in a pond and you have no idea what ripples will form or where.

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(s)

Hugh MacLeod is CEO of Canadian Patient Safety Institute. John Abbott is CEO of Health Council of Canada


Bellinger G. Host of Systems Thinking World. 


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