Essential Change Strategies

Structural

Political

Symbolic

Analyst Architect

Human Resource Catalyst Servant

Advocate Negotiator

Prophet Poet

Analysis Design

Support Empowerment

Petty tyrant

Weakling Pushover

Advocacy Coalition building

Inspiration Framing experience

Con artist Thug

Fanatic Fool

Management by detail Arbitrary decrees

Abdication

Manipulation Fraud

Mirage

Loss of clarity

• Communicate

and stability

• Realign

Confusion

• Renegotiate

Chaos

formal patterns

and policies

Anxiety and

• Train to de

uncertainty

velop new skills

People feel

• Encourage par-

incompetent

ticipation and

and needy

involvement

• Provide

psychological

support

Disempower-

• Create arenas

ment

where issues

Conflict be

can be renego-

tween winners

tiated and new

and losers

coalitions

formed

Loss of mean-

• Create transi-

ing and

tion rituals

purpose

• Mourn the

Clinging to the

past, celebrate

past

the future

Source: Adapted from Bolman & Deal, 2003.

senior leaders will find as they use each framework to address organizational change and the making of meaningful work.

Greenleaf

In the middle of the twentieth century Robert Greenleaf began leadership training under the auspices of AT&T. Over time he worked with many different organizations. In 1969, he gave a series of lectures at Dartmouth College that were to form the basis of his later work on servant leadership and his view of a leader who encourages the whole person—head, hand, and heart—to show up for work. In those lectures he identified a number of personal attributes, strategies, themes, and approaches that leaders might take in their own organizations (Frick & Spears, 1996). Table 4.3 briefly recounts the themes from these lectures. These decades-old points still offer helpful counsel to leaders today.

Kotter

John Kotter developed a powerful method for leading change, basing it on his study of successful and unsuccessful efforts to transform organizations. His model offers a change process comprising sequential steps that often overlap, run in parallel, and interact with one another (Kotter, 1996). Exhibit 4.1 lists these steps. In 1999, Kotter assembled several of his previous writings and appended some reflective comments on the differences between managing and leading change. He stated that leaders (1) set a direction, (2) align people, and (3) motivate and inspire people. He noted that the powerful path of "see-feel-change" works more often than "analysis-think-change," and he went on to suggest ways leaders can vividly speak to the feelings of those they seek to lead (Kotter & Cohen, 2002). Many health care leaders have found these suggestions to be very helpful.

Weick

A renowned expert on the psychology of organizations, Karl Weick urges leaders to consider their assumptions when trying to foster change (Beer & Nohria, 2000; Weick & Sutcliffe, 2001). Weick believes that when leaders seek to make intentional change, they should assume that any model of change will do, as long as it accomplishes the following:

• Animates people and gets them moving and generating experiments that uncover opportunities

• Provides a direction

TABLE 4.3. HIGHLIGHTS OF ROBERT GREENLEAF'S DARTMOUTH

COLLEGE LECTURES.

Theme Description

Goal setting Know what you are trying to do: the overarching purpose, the big dream, the visionary concept, the ultimate achievement that one approaches but never quite achieves. Goal setting's purpose is to excite the imagination. The right goal helps the rest of a leadership strategy to fall into place naturally. Principle of It is just as important to know what to neglect as to know what to do.

systematic neglect

Listening Listeners learn about people in ways that modify, first, the listener's atti tude; then, his behavior toward others; and finally, the attitudes and behavior of others.

Language as a A leader must articulate the goal. The effective use of language includes leadership some estimate of what the listener's fund of experience is plus the art of strategy tempting the listener into that leap of imagination that connects the verbal concept to the listener's own experience. One of the great communication arts is to say just enough to make that leap of the imagination feasible. In this process one must not be afraid of a little silence. In fact it is important to ask oneself, "In saying what I have in mind, will I really improve on the silence?" Recall that most of us don't like to be lectured to, but we all like to eavesdrop. Values We want a leader to be honest, loving, and responsible. Leaders are moved by the heart; compassion stands ahead of justice.

Personal growth The leader must be a growing person.

Withdrawal The best defense is to be able to withdraw, cast off the burden for a while, and relax. Optimum functioning includes carrying an unused reserve of energy in all periods of normal demand so that one has the resilience to cope with emergency.

Tolerance of We must have a view, rooted deep in our interior, that people can be imperfection immature and ineffectual but that even imperfect people are capable of great dedication and heroism. A lot of people are in fact unqualified to lead because they cannot work through and with the people who are available to work with them. Being your Be the natural person you are, and realize that you own yourself.

own person

Acceptance When followers feel accepted, they tend to perform beyond their limits.

Foresight What will happen in the future begins with a state of mind about now. The prudent person constantly thinks of now as . . . a moving concept—past, present moment, and future as one organic unity. This requires living by a sort of rhythm that encourages a high level of insight about the whole span of events, from the definite past through the present moment to the indefinite future. Leadership depends on intuiting the gap between the limit of the solid information and what is in fact needed for a dependable decision.

Source: Based on the material in Frick & Spears, 1996.

EXHIBIT 4.1. KOTTER'S EIGHT-STEP PROCESS FOR LEADING LARGE-SCALE CHANGE.

1. Tension for change: establishing a sense of urgency based on an understanding of realities of the market, crises, opportunities, and so forth

2. Coalition: creating a guiding coalition with enough power to lead the change

3. Vision: developing a vision and strategy that can direct the change effort, together with strategies for achieving that vision

4. Communication: communicating the change vision, using multiple modalities and vehicles for communication, and having the guiding coalition model the behaviors sought

5. Empowerment: empowering broad-based action while encouraging risk taking and removing barriers, obstacles, and undermining forces

6. Early success: generating short-term wins, and recognizing those wins and the people who contributed to making them

7. Expanding change: consolidating gains and producing more change to extend the vision for change beyond the initial targets and people

8. Grounding: anchoring the new approaches in the culture of the setting

Source: Adapted from Kotter, 1996.

• Encourages updating through improved situational awareness and closer attention to what's actually happening

• Facilitates respectful interaction in which trust, trustworthiness, and self-respect all develop equally and allow people to build a stable rendition of what they face

Weick observes that as leaders seek to change an organization, they can assume that their organization will observe the either-or states listed in Table 4.4. A model closer to the either side might drive a leader to carefully design and plan a change. If the reality facing the leader looks more like the or side, the leader must recognize that the primary job will be to certify the goodness of the changes actually made (Weick, 2000).

Further, both Weick (2001) and Scott (1987) note that settings in organizations vary in the degree to which they manifest tight or loose coupling, as shown in Table 4.5. The job of the leader seeking to foster change varies depending on the coupling phenomena present, as illustrated by the change strategies shown in Table 4.6. Weick (2001) notes that systems with loose coupling (high differentiation and low integration) may appear ineffective when assessed by criteria tied to efficiency but may be more effective when assessed against criteria that index flexibility, ability to improvise, and capability for self-design.

Improving these loosely coupled systems does not necessarily require making them into more tightly coupled systems. Indeed, as Weick (2001) suggests, "the loosely coupled system may be thought of as the social and cognitive solution to

TABLE 4.4. EITHER-OR STATES OF ORGANIZATIONAL CHANGE.

Either

Move from one state to another in a forward direction through time.

Move from a less-developed state to a better-developed state.

Move toward a specific end state, often articulated in a statement of vision.

Move only when there is disruption and disequilibrium.

Move only in response to forces planned and managed by people apart from the system.

Source: Adapted from Weick, 2000.

Have repetitive periods of ebb and flow and of unraveling processes that then need to be reaccomplished. Move in an orderly sequence through cycles whose disruption creates a crisis: try various strategies, remember, and repeat those that seem to work. Be preoccupied with journeys and directions rather than destinations and end states.

Consider change effective when change restores balance and adaptive sequences.

Accept the reality that nothing stays the same forever.

TABLE 4.5. SYSTEM EXAMPLES ASSOCIATED WITH LOOSE AND TIGHT COUPLING.

System Characteristic Loose Coupling Tight Coupling

Parts are capable of semiautonomous action.

System has many heads.

Interdependence of system elements

Leadership

Stability of coalitions

Role of coordination and control Boundaries

Operational alignments

Role of structure and process

Individuals and subgroups form and leave coalitions.

Coordination and control are problematic. System boundaries are often amorphous. Assignments of actors or actions to the organization or environment seem arbitrary. Shift in view from structure to process.

Parts are capable of contingent, dependent action.

System has one or few heads.

Individuals and subgroups form and maintain stable coalitions.

Coordination and control are emblematic. System boundaries are pretty clear. Assignments of actors or actions to the organization or environment fit a rationale.

Focus on the structure, using the process to understand interdependencies.

TABLE 4.6. MATCHING CHANGE STRATEGIES TO THE COUPLING SITUATION.

System Characteristic

Loose Coupling

Tight Coupling

Interdependence of

Work on logic, purpose,

Change parts.

system elements

socialization.

Leadership

Work via influence,

Change leader's mind

charter, data.

or change leader.

Stability of coalitions

Focus on orientation and roles of participants.

Pick participants well.

Role of coordination

Use data, shared reviews.

Establish clear

and control

accountability.

Boundaries

Work on purpose.

Change the next systems, or create a different context.

Operational alignments

Focus on effects.

Explore the role-rationale connection.

Role of structure

Focus on the paths of

Work on structure

and process

interaction with the STAR

and function.

(separateness or differences, talking and listening, action opportunities, reason to work together) model.*

* For the STAR model, see Zimmerman & Hayday, 1999. Source: Adapted from Weick, 2001.

* For the STAR model, see Zimmerman & Hayday, 1999. Source: Adapted from Weick, 2001.

constant environmental change, to the impossibility of knowing another mind, and to limited information processing capacities" (p. 401).

When seeking high-reliability performance, as must be done in the organizations that Weick has studied in the nuclear power industry and on aircraft carriers, leaders have different concerns and often focus on what Weick and Sutcliffe call mindfulness (Weick & Sutcliffe, 2001). Leaders in high-reliability organizations share several characteristics:

• Preoccupation with failure

• Reluctance to simplify interpretations

• Sensitivity to operations

• Commitment to resilience

• Deference to expertise

Weick offers a vision of what the leader's work might be in complex organizations seeking highly reliable performance. Amalberti, Auroy, Berwick, and Barach (2005) note that in health care, some clinical microsystems, such as those engaged in blood banking or anesthesia for not-at-high-risk patients, operate in the zone of "highly safe, reliable" systems. However, most clinical medicine operates at much lower levels of reliability, with failure rates in parts per 10, 100, or 1,000. Weick offers leaders insight into the challenges of guiding high-reliability systems and into the process(es) of leading complex, adaptive systems.

Toyota Approach

Donald Berwick, president and CEO of IHI, has often said, "What we need in health care is a Toyota!" Because Toyota has had such profound worldwide influence on quality thinking and techniques, we will finish our brief review of leadership frameworks with this automaker's approach to a high-quality organization and will cover that approach in somewhat greater detail than we gave to those reviewed earlier. Three threads seem to contribute to the tapestry of Toyota's identity (Dixon, 1999; Fujimoto, 1999; Monden, 1993, 1998; Ohno, 1988; Toyoda, 1987; Womack & Jones, 1996):

• The way of work, or management philosophy, that the founders and their successors modeled

• The tools and methods of change, often described as the Toyota production system, or lean manufacturing

• The emergent learning process that—over time—has allowed deep organization learning to occur

Each is discussed in the following sections.

Way of Work. For more than twenty years Jeffrey Liker, a professor at the University of Michigan-Ann Arbor, has studied the Toyota way of work (Liker, 2004). He suggests that the Toyota way of work and the Toyota production system function as twin strands in the Toyota "DNA' (Monden, 1998; Ohno, 1988). Liker portrays his accumulated learning about the elements of Toyota's way of work and production systems with a pyramid (Figure 4.5) and with fourteen management principles (Exhibit 4.2), grouped according to the following four assumptions:

• The organization should be guided by a long-term philosophy.

• The right process will produce the right results.

• Add value to the organization by developing your people and partners.

• Continuously solving root problems drives organizational learning.

Liker (2004) also cautions that, "lean is not about imitating the tools used by Toyota in a particular manufacturing process. Lean is about developing principles

FIGURE 4.5. THE TOYOTA PYRAMID.

FIGURE 4.5. THE TOYOTA PYRAMID.

Clinical Microsystems
Source: Liker, 2004. Used with permission of the McGraw-Hill Companies.

that are right for your organization and diligently practicing them to achieve high performance that continues to add value to customers and society" (p. 41).

Tools and Methods of Change. The following list describes many of Toyota's numerous approaches to the reduction of waste in an organization, including methods such as smoothing the work flow, getting quality right, and standardizing work routinely employed in the Toyota production system (Fujimoto, 1999; Liker, 2004; Womack &Jones, 1996; Womack, Jones, & Roos, 1991). Many persons have worked hard to adapt these approaches to health care. Among the leading adopters of Toyota methods in health care are the Pittsburgh Regional Healthcare Initiative (http://www.prhi.org), Virginia Mason Medical Center (http://www.virginiamason. org), ThedaCare (http://www.thedacare.org), and IHI (http://www.ihi.org).

Toyota Production System Waste Reduction Methods

• Reduction of non-value-adding activities

• Foolproof prevention of defects

• Reduction of uneven pace of production

• Assembly line stop cord

EXHIBIT 4.2. TOYOTA'S FOURTEEN PRINCIPLES.

Philosophy

1. Base your management decisions on a long-term philosophy, even at the expense of short-term financial goals.

Process

2. Create continuous process flow to bring problems to the surface.

3. Use "pull" systems to avoid overproduction.

4. Level out the workload.

5. Build a culture of stopping to fix problems, to get quality right the first time.

6. Make standardized tasks the foundation for continuous improvement and employee empowerment.

7. Use visual control so no problems are hidden.

8. Use only reliable, thoroughly tested technology that serves your people and processes.

People and Partners

9. Grow leaders who thoroughly understand the work, live the philosophy, and teach it to others.

10. Develop exceptional people and teams who follow your company's philosophy.

11. Respect your extended network of partners and suppliers by challenging them and helping them improve.

Problem Solving

12. Go and see for yourself to thoroughly understand the situation.

13. Make decisions slowly by consensus, thoroughly considering all options, implement decisions rapidly.

14. Become a learning organization through relentless reflection and continuous improvement.

Source: Liker, 2004. Used with permission.

• Reduction of excessive workload

• Real-time feedback of production troubles

• Reduction of inventory by using the Kanban system (in which a replenishment signal transmits information, generally regarding the movement or production of products)

• On-the-spot inspection by direct workers

• Leveling of production volume and reduction of product mix

• Built-in quality

• Production plans based on order volume

• Cleanliness, order, and discipline on the shop floor

• Reduction of set-up change time and lot size

• Visual management

• Piece-by-piece transfer of parts between machines

• Frequent revision of standard operating procedures by supervisors

• Flexible task assignment for volume changes

• Quality circles

• Multitask job assignment along the process flow

• Standardized tools for quality improvement

• U-shaped machine layout that facilitates flexible and multiple task assignment

• Worker involvement in preventive maintenance

• Automatic detection of defects

• Low-cost automation or semiautomation with just enough functions

• Automatic shutdown of machines

Emergent Learning Process. Fujimoto (1999) notes that the Toyota manufacturing system today is not the result of a "grand design." Rather, he suggests that several manufacturing process elements have been adopted from other settings and combined with relentless reflection on the efforts needed to change, improve, and standardize work—yielding new insights into the process of system development.

This emergent learning fuses learning with continually improving operations and resembles Argyris's concept of double loop learning: that is, learning coupled with learning about learning (Argyris, 1991). Fujimoto suggests that the simple principle that permeates the complex structure of Toyota is the shared aim of "outperforming rivals in attracting and satisfying customers by all employees" (Fujimoto, 1999, p. 124). He claims that this is a key to maintaining the overall integrity of manufacturing routines. The comparable operating principle for health care might look something like the following:

BETTER PATIENT OUTCOME, BETTER SYSTEM PERFORMANCE, BETTER PROFESSIONAL DEVELOPMENT BY EVERYONE.

What might the tapestry of identity look like for health care leaders seeking organization-wide structures and processes with Toyota-like capability? Adopting Toyota ways is not the answer (Womack & Jones, 1996). Rather, weaving this tapestry may involve the following tasks:

• Identifying the roots and requirements of an operating-learning culture that makes local sense

• Demonstrating a theory of health care work that pursues never-ending improved patient outcomes by professionals working in reliable and efficient systems

• Securing a relentless commitment by all involved to reflect on the work and on the learning that arises from successful efforts to change and improve the work

• Using that learning and those reflective insights for the never-ending redesign of patient-centered care

Toyota has been an important contributor to some of the currently popular improvement methods such as lean design (Liker, 2004; Womack et al., 1991) and Six Sigma (Harry & Schroeder, 2000). It was and still remains true that the examples set by Toyota's founders guide the way work gets done. They modeled the improving and learning way of work at the local work site. Senior leaders in health care have an opportunity to model these practices and to create human resource systems that promote these actions throughout the organization. Macrosystem and mesosystem leaders (using Toyota as the exemplar) need to be able to teach these practices by sharing their own experiences with them and carrying them out in ways that are visible to all.

A Synopsis of Leadership Frameworks

The aforementioned experts who have written volumes on leadership and leading change offer a rich set of insights and possible paths of action. The following eight practices are particularly noteworthy for health care leaders:

1. Be clear about the current realities facing you now, including the assessments you make of your own organization's reliability.

2. Be prepared to use different and complementary frameworks for building knowledge, taking action, reviewing, and reflecting.

3. Link operations and learning at the site where the work is done.

4. Use balanced measures of outcome that reflect multiple, important dimensions of performance, and visually display the measures over time.

5. Infuse a coherent, understandable, dynamic, and uniting aim throughout the entire organization, forming a common interest around that aim.

6. Test change, learn from the effort(s), and engage in visibly leading the change.

7. Invite the whole person—cognitive ability, technical skill, values—to show up for work.

8. Practice vigilant, mindful operations.

Some Unique Features of the Health Care System

The leadership frameworks, which have much to offer health care leaders, have features in common as well as points of difference. For example, they are all based on observations of business and industry in general and are not grounded in the health care sector. So before we present our suggestions for health care macrosystem and mesosystem leaders, we look at what is different about health care. What are the factors that affect the challenges faced by its leaders? What might work perfectly for General Electric might fail miserably at County Memorial Hospital owing to fundamental differences in the two different sectors. This is not to say that health care leaders cannot learn from business leaders, but it is to emphasize that leadership approaches need to be thoughtfully adapted to the special circumstances of today's world of health care delivery.

A short list of some of these special features follows:

Role of health professionals in health care system. Change and improvement in health care services and health systems is inextricably connected with health care professionals. Changes must take into account the professional formation and professional identity of the persons whom patients depend on to provide needed care.

Patient-centered or provider-centered. In the past, care systems were often provider centered. In the future, the health system will become more visibly patient centered. The reality is that patients and careteams are part of the same system, as Lawrence Henderson observed in 1935. Health care is about relationships between patients and clinicians, between families and careteams, who share a common aim.

Endless need. Good health care is a societal goal and, many would say, a human right. Health care represents the conjunction of deep human needs, never-ending advancements in technology and science, and intelligent, creative people. This combination leads to the potential for unlimited costs, growth, and innovation.

Payment mechanisms. Attempts to contain health care growth and costs so far have concentrated on various reimbursement strategies to modify financial incentives—and more attempts will certainly be devised. The United States, which has gone from cost-plus reimbursement to price controls to managed care, now seems ready to move to pay for performance and value-based purchasing. We are entering a major change in the health care marketplace. Pay for performance represents a dramatic change in reimbursement, in which payment becomes contingent on quality and cost outcomes.

External agents. A diverse collection of accreditors, licensors, and regulators create an environment of rules, requirements, and measurements that exert a profound shaping effect on health care professionals and organizations.

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