Black Holes--an invisible danger to change initiatives
(text of video)
Neglecting or delegating these responsibilities is like pulling the plug on the best results, spread, and sustainability.
Alignment means that everyone who needs to be involved to make an improvement initiative a success has made it an important work priority and they also agreed on goals, meeting structures, roles, tasks, and timelines.
The hardest part of alignment
Though it seems like the hard part would be getting initial alignment, sustaining alignment over time is much harder. This is because improvement almost always requires changing habits and patterns of roles, tasks, ways of thinking, and ways of relating. And, no matter how much we want a particular improvement, changing habits of any kind is very hard—think of diet and exercise. In healthcare systems, work habits are especially tenacious because of complexity, many competing demands, and the high stakes of caring for patients.
As a result, anyone in this situation is likely at one point or another to have a hard time sustaining enthusiasm and attention on problem solving for a new initiative. When this happens, gaps in alignment emerge and manifest in such signs as missed meetings, lack of follow through, decisions which do not include the right people, trouble sustaining changes, resistance, conflict, and people working at cross purposes.
Leadership power failures
Leaders are just as subject to complexity and competing demands. But, when leaders lose enthusiasm, attention, and focus, the result is like a “power failure” for the initiative. The reason the impact is so large is that there is an automatic tendency for people to align what they pay attention to with the priorities of their direct supervisors. When leaders drop out of alignment, people who directly report to them tend to do so as well.
A story of power failure
For example, several years ago I was helping quality consultants for a large, state-wide organization making what seemed like an easy change. While the senior leaders had “signed off” on the initiative as a priority, the responsibility for moving it forward was handed off to the quality department. The senior leaders did not make the initiative a priority agenda item in meetings with their vice presidents who then largely neglected to do so with their regional leaders on down to the frontline physician and administrative leaders in all of the clinics.
This meant that barriers were often not identified and addressed. For example, while the initiative required relatively minor shifts in tasks for clinical staff, even these minor shifts required lot of thought in reorganizing work. Without leadership involvement and support, problem solving conversations did not happen in most clinics. In another clinic, a physician leader was so vocal in his resistance to the extra work that it completely disrupted any work on the initiative. Difficult conversations were just not happening to address these issues.
In the first six months of the initiative, only five of 20 clinics showed any progress in results. When we looked deeper, those five clinics, unlike the others, had leaders who were actively involved in following progress and addressing barriers. They also helped staff create time for problem solving.
Two key leadership actions to prevent power failures
While the quality consultants tended to want to deal with these difficult conversations directly, I redirected them to start influencing the senior leaders to use their power to create structures and processes to sustain alignment. This included two key actions:
- The leaders needed to maintain attention on the change as a shared priority through ongoing meetings at least monthly to assess progress and address barriers with other leaders down and across the organization all of whom who then needed to do the same with the clinical and administrative teams they supervised.
- With emergent issues brought to them inside and outside of these review meetings, the leaders needed to take on difficult conversations and make decisions in a timely way.
Once the senior leaders put these actions into motion, almost all of the clinics achieved progress in the second six months. This came as a result of leaders assuring many hard but productive conversations including moving that highly negative physician out of his leadership position after he refused to budge from his resistance.
Leadership power failures are not solved by using top down, hierarchical methods. This is about staying engaged and supportive in order to identify and address difficult barriers to change. Sustaining alignment is an ongoing task that cannot be delegated away if leaders want to assure success.