References

1. Kahneman, Daniel Thinking Fast and Slow Farrar, Straus, and Giroux 2012.
2. Baker, Neil J. et al Hidden in Plain View: Barriers to Quality Improvement Physician Leadership Journal (2) Mar-Apr 2016, 54- 57
3. Lencioni, Patrick The Advantage Jossey-Bass 2012

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Tool for Ongoing Review Meetings for Improvement Initiatives
Available for subscribers only. Subscribe for free monthly resources and obtain a link to the tool by clicking on the subscribe button below . You may unsubscribe at any time. ​

​In this article you will learn that secrets to successful healthcare innovation too often stay hidden, why this happens, and what is needed to uncover them. 

Here are two brief stories of improvement initiatives told at conferences in which critical success factors emerged only when I later talked individually with the presenters. 

​In this article you will learn about the potential harms of trust and five safeguards or ground rules to prevent them. How we define trust is the important issue. 

References

1. Edmondson, Amy C. Teaming Jossey-Bass 2012
2. Salazar, Marco J Barzallo et al Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial J Am Coll Surg 219: 1001 – 1009, 2014

Additional resources

• Are you leading from reactivity or creativity?--four steps to see your blind spots

               Provides more details about indicators of "reactivity"--another term for "messiness."

• A Key Barrier to Making Our Leadership Transformational

               Explains a method to reflect on personal behavior to identify our own messiness.

• An Easily Missed Ingredient for High Team Performance

               Explains why team norms are so important and why it is so easy not to set them. 

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​Imagine someone has video-recorded you during every minute of your work the last week and you are now watching it. What are the odds that you will wince in some parts because of mistakes in the way you behaved or communicated?

References

1. Weisbord, Marvin R. Productive Workplaces Revisited Jossey-Bass 2004
2. Cooperrider, David Positive Image, Positive Action: The Affirmative Basis of Organizing in Appreciative Inquiry ed. by David L. Cooperrider et al, Stipes Publishing LLC 2000
3. Miller, William R., Rollnick, Stephen Motivational Interviewing, Second Edition The Guilford Press 2002

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​Our beliefs about what causes problematic behavior in others substantially impact our ability to influence change. ​

Tool
​A Four-Step practice--Guiding Questions
​
References
1. Ellis, Albert The Road to Tolerance Prometheus Books 2004
2. Kahneman, Daniel Thinking Fast and Slow Farrar, Straus and Giroux 2011

Reference List on Reactivity

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In this article you will learn about a four-step practice for a major leadership challenge—seeing our own contribution to problems. I discovered this challenge in my first leadership position supervising a staff of doctors and nurses at a hospital.  

An executive in a recent workshop I led pulled me aside to privately say:

“I know I need to reflect on the way I am thinking, feeling, and acting to be a better leader but I don’t know how.”

I was taken aback by his honesty. This was clearly hard for him to reveal. He chose not to ask in front of the group.

Reflection seems so straightforward. 
But is it?

What 420 leaders say about reflection…
It turns out the executive who pulled me aside is not alone. Of 420 healthcare leaders I surveyed at talks on leadership, almost all indicated they face one or more barriers to reflection. Two of the most common, each checked by nearly half of the leaders, were “uncertainty about how to do it well” and “lack of time.” 

The majority of written comments were about struggles with prioritizing and taking the time for reflection. Some of this was attributed to being “caught up” in issues such as “lack of trust in the organization” or “lack of political capital to get anything done.” One leader attributed his difficulty reflecting to “weakness.” Another wrote that it is “hard to change habits.” 

What brain science says about reflection…
At the heart of things, creating a reflective practice is creating a new habit. We all know changing habits like diet and exercise is hard. But I think reflection is much harder. In reflecting, we work to shift from being “caught up” in our thoughts and feelings to looking at them to expand our understanding of situations and open to more creative and effective options. 

Brain science has indicated that experiential information we take in is coupled to automatic, habitual ways of explaining events. Our brains are hard-wired for us to leap to conclusions from limited data in nanoseconds. It takes work to “decouple” ourselves from such automatic processes. But, even brief reflection such as taking 15 minutes to write down lessons learned from experience can yield more objective understanding of events and better options. (1 – 2) 

Hard-wired to avoid transformation 
Transformation involves getting to new perspectives. Because our brain hard-wiring can easily trap us into biased conclusions, we benefit from developing a regular practice of questioning our own thoughts. This is not easy for the ego. It is humbling. The tendency is to jump quickly to feeling “right” rather than leaving ourselves open to uncertainty. Think about how easy, common, and seductive it is to be sure other people are “the problem” rather than looking at our own contribution to problems. 

Missing the true level of our accomplishments
Another challenge is that our automatic responses can make it surprisingly easy to miss the true level of success we have had. Seeing our successes accurately is crucial to changing habits. 

For example, in the middle of a longer conversation, almost as an aside, a leader mentioned she had resolved a conflict with a team. I said “Wait! At the start of this conflict, what would you have estimated for the chances of achieving this level of success?” She replied “No more than a 20% chance.” Suddenly, this event became one worth reflecting on. How did she pull this off?

Three steps forward you can take right now
I guarantee you have already had multiple experiences of “decoupling” yourself from automatic thinking. The challenge is to turn such experience into an intentional and systematic practice. There is no way around carving out time. But, you can start small. For example, carve out one half-hour a week to reflect on a past or current situation.

Next, start trying out a consistent set of questions for guidance. Be willing to change them over time to find out what works for you. Here is a quick set to work from: What happened?; What were my thoughts, feelings, and actions?; What did I do that was helpful and unhelpful?; Where did I leap to conclusions?; How did I contribute to the problems?; What options might I consider?; What will I try next?; What do I hope to accomplish?

Finally, be sure to keep the goals for actions small to build confidence. For that leader who resolved the team conflict, her first step was to simply listen to the team and explore their concerns. That was transformational for her instead of needing a solution in one meeting. 

Consider engaging an extra set of neurons
The journey of developing a reflective practice also benefits from episodes of coaching and consultation. In my own work with clients, I think of myself as offering “an extra set of neurons” to increase power in countering hard-wired responses and generating creativity. In the wild complexity of organizational life, two brains can sometimes be better than one. 

Obtain tools for situational reflection and action planning 
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​References

1. Di Stefano, Giada et al Learning by Thinking: How Reflection Aids Performance, Harvard Business School Working Paper 14-093, March 25, 2014
2. Siegel, Daniel J. Mindfulness training and neural integration: differentiation of distinct streams of awareness and the cultivation of well-being, SCAN 2, 2007

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As humans, we are hard-wired to leap to assumptions in ways which create tension with others, especially under the pressure of stress and complex problems. 

This hard-wiring derives from ancient parts of the brain which evolved early on to generate automatic survival reactions--flight, fight, or freeze.

Difficulties in modern social situations can activate these pathways and drive us in nanoseconds, outside of our awareness, to faulty interpretations not infrequently accompanied by strong emotions. This happens to everyone. We cannot stop our brains from this quick process. But, we can modify it. One way is through stopping, even for a few seconds, to observe the mind.

The Ladder of Inference (1,2) is a tool to make visual these rapid movements of the mind and help us pause for reflection before we take action. The bottom rung of the ladder represents all the observable data in a situation. Our hard-wiring leads to rapid selection of part of the data and then "up the ladder" to judgments or assumptions, and finally to conclusions and action at the highest rung. Such actions are at risk for being unproductive or counterproductive for work relationships and problem solving. 

The Ladder can be divided into as many as 7 or more steps to represent schematically the brain's information processing. There is not one right number of steps. I use four because that is all I can remember in the midst of conflict which is when I use the tool to mentally orient myself. In the example shown above, my brain causes me to get very negative about a colleague, Chris.

• At the bottom rung is all observable data I could consider from my working relationship with Chris or even just for this one day.
• At the next higher rung, the brain selects data out of this pool. This day, Chris is late to a meeting and does not apologize. Because this has happened before and/or because I am particularly sensitive that day, my brain immediately focuses on that one piece of data.
• From selected data, the brain moves to judgments, assumptions, and opinions--i.e. making meaning out of the selected data. In this case, I assume Chris is totally disengaged and not committed to the team.
• At the highest point of the ladder, conclusions and actions are taken. I am gripped by my interpretations to the point that I don't think I can work with Chris. Or, I might withdraw from Chris, disrupting the flow of work between us. Or I might publicly attack him for his "bad attitude" (an interpretation which has not been checked out).

If we keep the ladder in mind in the midst of conversations, we can step back to observe our own thinking. We can shift to asking questions which move our thinking back to data and experience opening us to more choices for communication and action.  We can ask:

• What am I thinking?
• What interpretations and judgments have I made?
• On what data am I basing these conclusions?
• What is my reasoning?
• What other data am I not considering?
• What else could be going on?
• What other interpretations are possible here?

I can then use these same questions with others if I have sensed they have moved up the ladder. 
Research from Gervase Bushe (3) suggests that about 80% of conflicts at work occur because people have not checked out their experiences with each other--i.e. moving down the ladder with each other to share observed data and experience. When such sharing does occur, the conflict often either goes away or the issues are entirely different from what was expected.

Though simple in concept, sharing experience in this way can be very demanding because we may be gripped by strong emotion or the stakes may feel high or we may just have a strong need to be "right" at that moment. Then it can be hard to own our contribution to the tension. Slowing down to reflect requires a good deal of self-regulation of emotion and thought.

The Ladder of Inference reminds us to treat our strongest conclusions as just theories to be tested. Our first conclusions are all too likely to put us at risk for becoming part of the problem. 

References
(1) Attributed to Chris Argyris and Donald Schon. See a brief history of the development of the Ladder of Inference in
     Diana Mclain Smith The Elephant in the Room, 2011, pgs. 275 - 276
(2) Thanks to the American Academy on Communication in Healthcare for the Ladder of Inference image.
(3) Gervase Bushe Clear Leadership, Davies-Black, Nicholas Brealey Publishing 2010

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How often do you deal with people at work who cause headaches due to what seem like deeply ingrained personality issues?

There is hope.

(See the full article online at Unexpected transformations. The following are brief excerpts).)

In the large majority of circumstances of such difficult behavior, situational factors are the predominant driving forces—not personality traits or even lack of skills.
Quite often, these situational factors are amenable to change.

Psychological research has shown that attributing difficult behavior to fixed personality traits as opposed to situational factors (the “fundamental attribution error”) is a pervasive and nearly automatic cognitive bias.

Multiple researchers (e.g. Ellis, Argyris) find that, no matter how smart and successful people are, everyone falls into counterproductive behavior at times—especially under complexity and stress.

The good news: this means that at any given moment what we see around us as lack of communication or "people" skills could, not infrequently, be a temporary, quite human reaction to complexity and stress.

And, at any given moment, there is likely to be a large amount of unused leadership capacity in any organization to tap into. For more research see: Invisible Barriers to Communication

Right now, what percent of leaders face a challenging work situation with problematic behaviors in people and which, if improved, would significantly impact their work-lives?

At a recent workshop, the answer was 91% of 263 leaders.

The main causes of situational behavior are captured in Kurt Lewin’s equation  B = f (P, E)—behavior (B) is a function (f) of the person (P) (e.g. personality) and the environment (E). In tough situations, the human tendency is to blame (P). The ability to influence change depends substantially on focusing on (E).