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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​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. 

When facing difficult relational problems at work, it is natural and nearly automatic for us all to want to diagnose what is wrong and come up with THE right solution as soon as possible.

It is very common to leap quickly to strong but faulty conclusions. One example is attributing relational problems to personality issues or lack of skills. Actually, situational issues are far more often the primary cause of difficult behavior. 

Situational complexity and stress are inherent in organizational life. These factors easily provoke differing viewpoints and experiences among the people involved. Relational problems arise most frequently when these differences have not been adequately heard and understood. Pushing for a solution prior to such understanding runs a substantial risk of negative reactions and push back. 

Resisting the rush to diagnoses and solutions and taking the time for “dialogue and discovery” usually leads to much more success. By engaging in dialogue, a process of hearing and understanding different viewpoints, new perceptions and solutions emerge surprisingly often. 

While there are no recipes or scripts, the following three steps provide guidance. 

1. Reflect—recognize and manage leaps to conclusions in yourself

• Set aside certainty that there is ONE correct viewpoint (no matter how certain you are). Prepare to state your view with the aim of being understood, not “getting” agreement. 

2. Dialogue—first, set aside finding solutions in order to build mutual understanding

• State your intention to first understand each other even if there is disagreement. Be vigorous in assuring accurate learning about different viewpoints by avoiding debates and repeatedly summarizing and checking for understanding.    

3. Decide—seek agreement to meet again (expect multiple conversations for resolution)

• Take small steps over multiple conversations to enable the best chances for a mutual solution. It also helps to have clarity about how a decision will be made if and when that becomes necessary (e.g. by consensus vs. by a person with the authority to decide).

The first step can be the most difficult. When the stakes feel high, at times we all have unproductive habits of reaction. These take practice to change and, sometimes, coaching. 

The productive habit we need to continuously strengthen is counter-intuitive: we need to slow down the rush to solutions and take one small step at a time through dialogue and discovery. This enables the chances for the best success for both task and relational goals.  
 
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Not only are there hundreds of thousands of books on leadership and associated topics but they offer a bewildering variety of frameworks, models, and terminologies. 

On the one hand, this is a very good thing. Having served as a leader for many years, I have been deeply appreciative of many great approaches. 

But, as a leader, I usually faced a huge number of issues every day. It was hard to recall more than a few strategies in the moment. 

So, all through my career I have sought one short list of strategies for easy reference that would be powerful in problem-solving across many types of situations.  

Could it be possible to create such a list? Find out more in the Resource Guide for In-the-Moment Leadership Strategies available for subscribers only. Click on the button below to subscribe for free monthly articles and obtain a link to the Guide as well as other resources. 

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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. 

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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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Barriers to progress like lack of alignment or conflict that are difficult to resolve are fairly common. One seemingly quite logical interpretation is that the primary cause of such barriers is the way people are communicating.

But, problematic communication could be secondary to--a result of--flaws in decision-making processes. Such flaws may not be recognized as an important source of relational problems. When people then dive into discussions, they are at risk for having unexpressed concerns, differing views, and assumptions about how decisions will be made.

As a result, it is more difficult to sustain dialogue—a process of eliciting and assuring mutual understanding of differing ideas, opinions, and perceptions. Instead, due to the prevailing uncertainties, people are more likely to fall into debates, arm-twisting, coaxing, and pressuring which disrupt efforts to achieve alignment.  

Identifying flaws in decision making and doing something about them can help significantly to shift a murky, entangled debate into a clear, effective process of dialogue.

Common decision-making errors include lack of clarity about: who has the authority to make the call; the type of decision being used; whether there will be input before and after decisions are made in order to address concerns; or if those impacted will be involved in the design of the implementation plan.

A quick diagnostic for flaws in decision making process (to support high quality dialogue):

• In this situation, is it clear who (person or group) has the authority to make the decision?
• Has that person or group identified the type of decision making to be used? (see brief descriptions below)
• Is there a clear timeline for the decision?
• Do people who are impacted and those who can contribute expertise have opportunities to give input? Have they been involved in creating a mutual definition of the problem?
• Has there been high quality dialogue prior to the decision with consideration of different options and the benefits and risks of each?
• Will there be opportunity to express reactions and address concerns about a decision after it is made?
• Will people be involved in designing the implementation plan for the decision?
• Will the person or group who made the decision engage in regular review of the quality, clarity, and effectiveness of decision making processes?

Types of decision making: (1)
The following two decision types mesh best with the objective of promoting high quality dialogue.

• In consultative decisions, a leader with the authority to do so makes the call after obtaining input through dialogue from those who will be impacted and those who have key knowledge and expertise.

• In consensus, a group of people make the call together. Consensus does not mean that the decision is everyone’s first choice but that everyone can live with the decision and commit fully to its success.

Additional decision types:

• In authoritative decision making, a leader with authority makes the decision without input. Dialogue about the decision after it is made is crucial to promote alignment and participation in implementation.

• When decisions are delegated, a leader with authority gives that authority to another leader or team who then determines the decision type and process to be used. 

Maintaining high quality dialogue while also maintaining clarity and quality of decision making processes is an important and nuanced balancing act. It takes art, skill, and ongoing, deliberate practice by individual leaders and by teams.

Additional brief articles on decision making

• When Decisions Cause Distress--a path of courage and compassion
• We have a consensus!?

Reference
(1) Special thanks to Robert Crosby. See his book Walking the Empowerment Tightrope 1992.

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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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"The single most important skill to have in working through any problem is the ability to give constructive feedback. Why? Because most often problems are expressed as criticism of someone's actions." (1)

The stakes for feedback are higher on teams because "learning what several people expect of you is far more difficult than learning what one other person expects and needs." (2)  In effective teams, everyone helps each other to perform his/her role to meet expected outcomes--in Schein's words, "perpetual helping." But, feedback is the key mechanism for this helping. It is a means of constant course correction.

Because of the nature of personal exposure with feedback, the environment of trust on teams is essential. As Schein states, "What we think of as respect or trust is basically the feeling that you will not be humiliated or embarrassed even if your behavior deviates from the norm and is viewed as unhelpful. Instead you get task relevant information that allows you to figure out how to become more helpful in the effort to achieve goals." (2)

Helpful feedback is an art and skill which only develops with intentional practice. Practice gradually normalizes the discomfort of feedback.(3)  Over time, a feedback-rich culture can make feedback less a source of anticipated discomfort and more a source of desired learning. 

Key components of productive feedback include (from references 1 and 2):
(a) prior setting of team norms and work process specifications
(b) specific, concrete, behavioral descriptions related to achieving goals (not good vs. bad)
(c) avoidance of labels, generalizations, and characterizations (e.g. "You are lazy.")
(d) using "I" statements and owning feedback as perceptions as opposed to "Truth"
(e) asking for the other person's perception in response
(f) stating genuine positive regard along with the feedback wherever appropriate

References
(1) Schein, Edgar Helping: How to Offer, Give, and Receive Help Berrewtt-Koehler Publishers,Inc., 2009
(2) Scholtes, Peter R. et al The Team Handbook, Third Edition Oriel Incorporated, 2003
(3) Brown, Brene Daring Greatly Gotham Books, 2012

In complex systems, issues that look like problems to solve through "either/or" arguments are often really polarities in disguise. Polarities are issues for which there are "two or more interdependent right answers." (1)

Both sides of a polarity need to be explored and managed well if solutions are to be sustainable. Unbalanced solutions overemphasizing one side of a polarity will lead to swings back and forth between opposing strategies over time. (1)

Wicked questions (2,3) can be used to facilitate movement from "either/or" arguments into "both/and" dialogue. They are designed to help teams jointly address the upsides and downsides of each part of the polarity equally, without judgment or blame.

Examples of wicked questions (from Ref. 3 below): "What opposing-yet-complementary strategies do we use simultaneously in order to be successful?;" "How is it that we have ____  and we have _____simultaneously?;" "How does each side of this polarity have benefits?;" "In what ways does each side of this polarity lead to liabilities?"  It helps to offer up front education about polarities and to provide facilitation to help move from debate to mutual exploration.

For example, an argument framing a problem as whether to use directive vs. participatory decision making styles could be re-framed by asking "In what ways do we need both? What are the benefits and risks of each approach?" The aim is to create solutions which maximize benefits and minimize risks of each side of the polarity. (1)  For example, benefits of a directive style include more timely and efficient decisions. The risks can be squelching of individual initiative and less motivation. A participatory style might mitigate these downsides but, if overused, could lead to its own problems--such as decisions getting mired down in group process.

Examples of other polarities include: top-down control vs. bottom-up individual/team freedom and initiative; stability vs. change; centralized vs. decentralized planning and implementation; and equality vs. hierarchy. There is evidence that companies which are visionary, successful, and enduring are able to embrace polarities, especially about top-down control vs. freedom and initiative. (4)

Research in positive psychology suggests that "how you celebrate is more predictive of strong relations than how you fight." (Martin E.P.Seligman Flourish, 2011)

Capitalizing on positive actions, experiences, and events to improve satisfaction, well-being and quality of relationships involves offering detailed, nuanced responses rather than the more common brief exclamation. Here are two types of situations and the recommended approach.

(1) When someone does something you appreciate, offer positive regard. (termed "ongoing regard" in Robert Kegan and Lisa Lahey How The Way We Talk Can Change The Way We Work, 2001)

More powerful positive effect is achieved by offering behaviorally specific information rather than a brief, general response--e.g. "I really appreciate the way you took the time before our meeting to summarize the key supporting data. That really facilitated our decision making." This is in contrast to the relatively common "You did a great job!"

The detail in the first response is likely to feel more thoughtful and genuine than the more vague and global "great job." Also, starting with "I" rather than "You" makes it feel more like the speaker is offering potentially valuable information from experience for the receiver to consider rather than conferring some form of judgment. The latter can subtly diminish any intended positive effect.

(2) When someone reports experiencing a positive event, respond in an active-constructive way. Such responses have been linked by research to increased well-being and relationship benefits such as increased commitment and trust. (Shelley T. Gable et al in Advances in Experimental Psychology Vol. 42, 195-257, 2010)

As with positive regard, benefits are achieved by going beyond the more usual brief exclamation (e.g. "That's great. Congratulations.") and asking questions about the event, seeking additional details, elaborating on the possible implications and benefits for the discloser, and commenting on why the event is meaningful to the discloser in particular. Such responses are also more powerful when accompanied by conveying emotions of interest, happiness, or pride. (Gable et al, 2010)

One method of group decision making I have observed, not uncommonly, is for someone to vigorously put forth a proposed decision and look around the room.

A few people remain silent and still, a few nod their heads, and maybe one or two exclaim “Yes.” Then the person who wants the decision announces: "We have a consensus!" (After all, "everyone agreed--no one stated any objections.")

Poor implementation and outcomes in such situations are quite likely. High quality consensus requires that each person give explicit indication of being able both to live with the decision and to fully commit to successful implementation—even if not fully satisfied. This occurs only with balanced, fair, and rational discussion in which everyone participates and everyone feels heard. (Chris Mcgoff The Primes, 2012 and Peter Scholtes et al The Team Handbook, 1989)

Poor quality consensus decisions result from lack of a shared definition of consensus, lack of a systematic and clear way for each person to indicate if they are in consensus, and arguments and debates as opposed to assuring all opinions are fully heard. Also, use of traditional definitions like "no one voices objections," "everyone agrees with everything," "everyone is fully satisfied," or "majority rules" are not effective and perhaps even destructive to the best efforts. (McGoff, 2012)

Groups have used a wide variety of methods for each person to specifically indicate if they are in consensus: An example is to use a scale of 1 - 5  with "5" meaning a high level of enthusiasm and "1" meaning no enthusiasm. A cut-off is defined (e.g at a rating of '1" or "2" even from just one person) which means insufficient enthusiasm to commit to implementation. The effort to come to a decision would then stop and dialogue would be restarted. This might lead to revision of the proposed decision or a shift in enthusiasm due to deeper exploration of issues. This iterative process increases the odds of a creative decision and shared motivation for implementation.

High quality consensus decision making is not easy. It requires high quality dialogue so that decisions reflect the thinking of all group members. The skills for moving back and forth between checking for consensus and dialogue require a good deal of intentional practice over time.