leading adaptive change: a framework to transform healthcare

© 2014 Health Catalystwww.healthcatalyst.comProprietary and Confidential


Val Ulstad MD, MPH, MPA

Leading Adaptive Change


Why Adaptive Leadership?

• Describes what people do• Describes what people exercising

leadership can do if they see differently• A way of developing a shared language

to describe group dynamics• Describes a way to be an active

engaged organizational citizen• Really resonates with professionals in

health care


Adaptive LeadershipWork of Ron Heifetz, M.D.

People adapt more successfully to their environments by facing painful circumstances and developing new

attitudes and behaviors.


Productive Range

Threshold of learning

Limit of tolerance

Time

Tens

ion

of c

hang

eCONCEPT #1

Productive Range of Tension

Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.


Productive Range


Limit of tolerance

Time

Ten

sio

n o

f c

ha

ng

eHuman Systems

Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

I understand the reality of my condition.I am looking to you for guidance and honesty.I understand what I need to do.

I don’t want to hear any more bad news.I can’t make sense of any of this.I am so terrified I don’t understand a word you are saying.

I came for a pill or gadget to fix this.


Productive Range


Limit of tolerance

Time

Ten

sio

n o

f c

ha

ng

eHuman Systems

Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.


CONCEPT #2Types of Situations Requiring Leadership

Technical - Apply abilities that already exist in the system’s capabilities

Adaptive - People deeply and broadly within the organization need to learn new capabilities


Address the Gap Between

The Way Things are

and Achieving the Triple AIM

Improved Health of the Population

Enhanced Patient Experience of Care (not forgetting the experience of the people who provide it)

Reduce (or at least control) Total Cost of Care

The Challenge


Properties of an Adaptive ChallengesWicked Problems

•Gap between way things are and desired state

•Varied points of view

•Requires difficult learning

•Involves facing loss

•New competencies must be developed

•People with problems have problem solving responsibility

•Takes longer than technical work

•Requires trying things

•Generates disequilibrium, distress and work avoidance


The most common cause of leadership failure is treating an adaptive challenge

with a technical fix.


Question #1What is the work?

Gap = difference between the way things are and the desired state

Start somewhere meaningful and manageable


Adaptive WorkDiminishes the gap between the way things are and the way things need to

be to create a better future

Adaptive leadership is the activity that mobilizes people to perform needed

adaptive work


Adaptive Work

You

Question #2 Who Cares About the Work?


Organizations are illusions; they are just groups of relationships

- Parker Palmer


When you consider Lincoln, did he embody -

Authority?

Leadership?

Both?


Authority Leadership

• Leadership is an activity• Authority, power and influence are tools

but do not guarantee leadership- necessary but insufficient


CONCEPT #3There is a difference between the role of authority and the exercise of

leadership.


Authority (whether formal or informal)

is necessarybut insufficient for the exercise of leadership.

Ability to constructivelyinfluence

is acritical resource for leadership

even when/if you have a big title.


Developing Influence

• Assess their capability

• Help them see what’s in it for them

• Earn trust

• Speak to their perception of cost

• Acknowledge their perception of risk Adapted from C. Dwyer, The Shifting Sources of Power and Influence,

Amer Coll of Phys Executives, 1992


Your Success at Influencing Another

•Their capability to do what you ask

•Plus +• (Their Perception of Potential Benefit X Their Perception

of the Probability of the Benefit Really Happening)•Minus -

• (Their Perception of Cost -Their Perception of Risk)

It’s all about perception.


Developing InfluencePerception Matters

You will tend to over focus on

● Potential gain to other

● Extent to which you are trusted

Other will tend to over focus on

● Potential personal risk

● Potential personal cost

Adapted from The Shifting Sources of power and Influence – Dr. Charles E. Dwyer


Emotional Bank Account

Adapted from S. Covey Sr., Seven Habits of Highly Effective People, Simon and Schuster, 1999

EsteemAcceptanceRespect


Emotional Bank Account Balance Sheet

Courtesy

Kindness

Honesty

Keep commitments

Discourtesy

Disrespect

Interrupting

Overreacting

Causing another to feel ignored

Becoming arbitrary

Betraying trust

Threatening


Esteem

Acceptance

Respect


Build Up The Emotional Bank Account• Understand the individual

● seek to understand the way you want to be understood

• Attend to the little things ● be kind and courteous

• Keep commitments

• Clarify expectations

• Personal integrity● Walk your talk

● Be loyal to those not present

• Sincerely apologize when you make a “withdrawal”



People will trust you when you fulfill their expectations (their wants and needs).

Your balance increases in their emotional bank account

People will distrust you when you fail to fulfill their expectations (their wants and needs).

Your balance decreases in their emotional bank account

Constraints of Authority


Exercising leadership to do adaptive work

means disappointing people’s

expectations at a rate they can tolerate.


Exercising leadership to do adaptive work

means disappointing people’s

expectations (that things will stay the same)

at a rate they can tolerate.

(and not ignore you or try to silence you or resist in infinitely creative ways)


Resistance (passive or active)

• A signal that you are losing influence and are exceeding the amount of loss and uncertainty they can tolerate.

• Clarify your intentions

• Refine your approach to the tensions between perspectives (conflicts) inherent in the issue

• Try again to help the group make progress


Productive Range


Limit of tolerance

Technical challenge

Time

Making Progress on Work

Adaptive Challenge

Ten

sio

n o

f ch

ang

e

Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.


Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

eThe Work

Distress

Distress



Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

The WorkWhat People Will Not Tell You, Their Behavior Will Reveal

Blame others, distract attention, denial


Distress

Distress



CONCEPT #4Work Avoidance as a Signal of Being Outside

the Productive Range of Tension

37


Work Avoidance (Resistance)

• Displacing responsibility

• Attack authority

• Kill the messenger

• Scapegoat

• Distracting attention• Pretend to be busy• Define problem to fit your

competence• Make the problem too big• Restructure/reorganize• Meetings with only information

exchange when engagement is needed

• Pick a fight

• Denial• Flavor of month?


Work Avoidance (Resistance)

• Displacing responsibility

• “The rest of my team is incompetent”

• “Our coach is not doing their part.”

• “This is a passing fad – the leaders don’t really want this”

• Distracting attention• “This cookbook medicine!”• “This all about money not

care.”• “I am too busy – I have a day

job”• “I can’t ask my colleagues to

do that!”• Excuses for missed meetings• “I am losing income to do this

work”

• Denial• “This work will not change

anything”• Not showing up

39


PRODUCTIVE RANGE

HOLDING ENVIRONMENT

Work avoidanceThreshold of learning

Limit of tolerance

Technical challenge

Time

Adaptive Challenge


Work avoidance

Ten

sio

n o

f ch

ang

eAre You Reading the Signals People are Sending You?

Work Avoidance Signals Being Out of Productive Zone


Resistance/Work Avoidance

When people resist the change you are helping them face and avoid the work – which of the following is true?

a. It can mean they just don’t think the issue requires their involvement

b. The rate of change is too much for them to tolerate

c. It can mean they are overwhelmed and don’t know what to do next

d. It means you need to try a new “test of change”

e. All of the above

41


Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

eThe Work

Distress

Distress



What Does Work Avoidance/Resistance Tell You?

Interpreting stakeholder behavior when they are engaged about the work

Which ones are above the limit of tolerance?

Heat too high

Which ones are engaged in the work?

Heat is in the zone to keep things cooking

Which ones are below the level of learning?

Heat too low


Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

The WorkWhat People Will Not Tell You, Their Behavior Will Reveal



Distress

Distress



Adaptive Work

You

Question #3 How are the people who care about the work reacting to the work?

What does the work avoidance suggest?


Which statement best represents how you are feeling? Choose one

1. I feel like I’m taking a drink from a fire hose; I’m overwhelmed

2. Seems like good common sense to me; I’m with you, keep going

3. This really doesn’t apply to me ; I’m not in charge, so I’m not sure I need this

46


Productive Range


Limit of tolerance

Time

Ten

sio

n o

f c

ha

ng

eWhere We are Right Now

Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.

Taking a drink from a fire hoseOverwhelmed

Seems like good common sense to meI‘m with you, keep going

This doesn’t really apply to meI’m not in charge, I don’t need this


Question #4 What Do I Do Next?

• Use yourself differently

• Keep people who are making progress engaged and figure out what you need to do to reengage others.


Use Yourself Differently

• Pay attention

• Set a great example

• Celebrate and learn from what is going well

• Talk about why you think this is important

• Ask questions

• Listen

• Reflect in action


CONCEPT #5Reflect in Action

Get on the Balcony and Dance


Balcony AND Dance Floor

Over focus on Balcony Over focus on Dance floor


Question #4 What Do I Do Next?

• Use yourself differently

• Keep people who are making progress engaged and figure out what you need to do to reengage others.


What do you need to do to make progress?

What can you do to lower the distress on the factions that are above the limit of tolerance?

How can you maintain engagement of factions that are currently engaged in trying to make progress?

What can you do to raise the distress to a

productive level for the factions below the level of learning?

Begin to Plot a Strategy


Think about a time when the heat was too high.

What did you do to bring things to a productive level of tension so progress

could be made?


Lower the Heat

• Validate feelings; acknowledge loss

• Simplify and clarify

• Restore, add or reallocate resources


Think about a time when the heat was too low.

What did you do to bring things to a productive level of tension so

progress could be made?


Raising the Heat

• Raise the standards

• Increase accountability

• Change the task to something more motivating

• Refocus on higher, more widely shared and yet compelling purpose


PRODUCTIVE RANGE

HOLDING ENVIRONMENT

Work avoidanceThreshold of learning

Limit of tolerance

Technical challenge

Time

Adaptive Challenge


Work avoidance

Ten

sio

n o

f ch

ang

eAre You Reading the Signals People are Sending You?

Work Avoidance Signals Being Out of Productive Zone


Resistance (passive or active)

• A signal that you are losing influence and are exceeding the amount of loss and uncertainty they can tolerate.

• Clarify your intentions

• Refine your approach to the tensions between perspectives (conflicts) inherent in the issue

• Try again to help the group make progress


Exercising leadership requires keeping an experimental mindset

• Work avoidance looks the same when the heat is too high or when the heat is too low.

• Keep rechecking your assumptions.

• What looks like laziness may be exhaustion.

• If what you try makes things worse try the opposite.


Nobody misbehaves from a place of strengthStart with CompassionWhen you don’t know what to try first,

lower the heat

• Validate feelings; acknowledge loss

• Simplify and clarifyo Address the technical aspects

o Break the problem into parts

• Restore, add or reallocate resourceso Temporarily reclaim responsibility for tough issues

o Give your attention

o Take stock of what is available

o Allot more time, enrich knowledge and skills


CONCEPTS• Productive range of tension• Difference between technical and

adaptive work• Difference between role of authority

and the exercise of leadership• Work avoidance as a signal of being

outside the productive zone• Reflect in action


Leading Adaptive ChangeFour Questions

What is the work?

Who cares about the work?

How are people who care about the work reacting to it?

What do I do next?- Use your self differently

- Regulate the heat


Technical vs. Adaptive workClear answers, minimal uncertainty

Straightforward, few big choices

Execute via precise instructions

Requires hands, feet, mouths

Focus on task

Linear, demands precision

Runs smoothly

No clear answers, often high

uncertainty

Time-consuming, difficult choices

( losses)

Demands lots of conversations

Requires hearts, eyes and ears

Focus on people connected to

task

Spiral with feedback loops,

demands creativity

Conflict and distress


Thank you!!


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