session 31 leading adaptive change to create value in

Session 31

Leading Adaptive Change to Create Value in Healthcare

Val Ulstad MD, MPH, MPACEO Partners at Cascade Bluff LLC

Leading Adaptive Change to Create Value in Healthcare

Poll Question # 1

4

Adaptive WorkWhat percentage of your work is adaptive?

1) 0% to 25%2) 25% to 50%3) 50% to 75%4) 75% to 100%5) Unsure or not applicable

• 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, and organizational citizen.

• Really resonates with professionals in healthcare.

Why Adaptive Leadership?

Adaptive Leadership

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

Work of Ron Heifetz, M.D.

Productive Range

Threshold of learning

Limit of tolerance

Time

Tens

ion

of c

hang

e

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

CONCEPT: Productive Range of Tension

I am so terrified I don’t understand a word you are saying.

I don’t want to hear any more bad news.

I can’t make sense of any of this.

I came for a pill or gadget to fix this.

I am looking to you for guidance and honesty.

I understand the reality of my condition.

I understand what I need to do.

Time

Tens

ion

of c

hang

e


CONCEPT: Productive Range of Tension

Productive Range


Limit of tolerance

Human Systems

Productive Range


Time

Tens

ion

of c

hang

e


Limit of tolerance

CONCEPT: Types 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.

The Challenge

The way things are

Address the gap

Achieving the Triple Aim

• Improved population health.• Enhanced patient care experience

(not forgetting the experience of the people who provide it).

• Lowest appropriate total cost of care.

c

The hard work ahead demands we create value and stay resilient.

Why is it so hard?

Properties of Adaptive Challenges

• Gap between way things are and desired state

• Varied points of view

• Involves facing loss

• Requires trying things

• Requires difficult learning

• Takes longer than technical work

• New competencies must be developed

• Generates disequilibrium, distress, and work avoidance

• People with problems have problem-solving responsibility

Wicked Problems

Technical challenge

Adaptive Challenge


Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

Technical and Adaptive Challenges

Technical and Adaptive Challenges• Flow charts• Affinity diagrams• Decision analysis tools• Measurement tools

Technical pieces are necessary but insufficient for adaptive work.

The conversations and insights they stimulate will help with the adaptive work.

The most common cause of leadership failure is treating an adaptive challenge with a technical fix.

Distinguishing Between Technical and Adaptive Challenges

• You’ll know it’s adaptive work…

• When people’s hearts and minds need to change; not just their preferences and routine behaviors.

• If the process of exclusion occurs when a technical approach has not worked.

• If conflict persists. Conflicts are symptoms; not the actual problem.

• When it becomes a crisis (crisis is often a good indicator).

KEY QUESTION: What is the work?

Start somewhere meaningful and manageable

The way things are

The way things need to be to create a better future

Diminish the gap

Adaptive Work

Adaptive leadership: The activity that mobilizes people to perform needed adaptive work.

The way things are

The way things need to be to create a better future

Diminish the gap

Adaptive WorkYou

KEY QUESTION: Who Cares About the Work?

Organizations are illusions; they are just groups of relationships.

- Parker Palmer

c

Courtesy of Judy Brown

Definition from Judy BrownNOT

DialogueDialogue is a form of communication based on the value of eliciting many perspectives in order to understand, and thus take wise action, in complex dynamic situations. It requires strengthening critical leadership and communication skills, among which are listening, awareness of one’s inner process, respect for differing points of view, tolerance of ambiguity, speaking from the heart, and one’s own experience.

Why Practice Dialogue?

• Increase the intelligence of the group

• Build and maintain trust

• Support sustainable and sustaining relationships

• Work together more effectively

• Address adaptive challenges (those for which there is no technical fix)

Key Practices

• 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

Stakeholder Analysis

• A critical success factor for any improvement project is your ability to identify those who will be impacted by your work; address their concerns and gain the appropriate level of support.

• It is an important first step in your engagement strategy.

• Will need revisiting regularly as conditions change.

Keep Satisfied

Meet Their Needs

Key Player

Manage Closely

Monitor

Minimum Effort

Keep Informed

Show Consideration

Low High

High

Low

Interest of Stakeholders

Pow

er /

Influ

ence

of S

take

hold

ers

Stakeholder Power & Interest GridCan help you prioritize

Authority Leadership

• Leadership is an activity.• Authority, power, and

influence are tools but do not guarantee leadership; they are necessary but insufficient.

There is a difference between the role of authority and the exercise of leadership.

CONCEPT

is a critical resource for leadership even when/if you have a big title

Authority(whether formal or informal)

is necessarybut insufficient for the exercise of leadership

is the ability to constructively influence

Adapted from C. Dwyer, The Shifting Sources of Power and Influence, Amer Coll of Phys Executives, 1992

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

Your Success at Influencing Another Their capability to do what you askPlus +• (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 Influence

You will tend to exaggerate the• Potential benefit to others• Extent to which you are trusted

Others will tend to exaggerate the• Potential personal risk• Potential personal cost

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

Perception Matters

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

Emotional Bank Account

Esteem Acceptance Respect

Emotional Bank Account Balance Sheet

CourtesyKindnessHonesty

Keep commitments

DiscourtesyDisrespectInterrupting

OverreactingCausing another to feel

ignoredBecoming arbitrary

Betraying trustThreatening

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 commitmentsClarify expectationsPersonal integrity• Walk your talk• Be loyal to those not present

Sincerely apologize when you make a “withdrawal”


cPeople 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.

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, try to silence you, or resist in infinitely creative ways)

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

How to respond:• Clarify your intentions.• Refine your approach to the tensions between

perspectives (conflicts) inherent in the issue.• Try again to help the group make progress.

Resistance Passive or active

Poll Question # 2 Understanding Resistance

43

When people resist the change you’re helping them face (answer “True” or “False” for each answer):

a) They are just trying to ruin your day. b) The rate of change is too much for them to tolerate. c) It indicates that you are gaining influence.d) It means you need to try a new “test of change.”

Technical challenge

Adaptive Challenge


Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

Making Progress on The Work


Technical challenge

Adaptive Challenge

Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

Making Progress on The Work

Distress

Distress


The Work

Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

Blame others, distract attention, denial


The Work


Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

What people will not tell you, their behavior will reveal

CONCEPT: Work avoidance is a signal of being outside the productive range of tension

Work Avoidance: Resistance

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

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

exchange only when engagement is needed

• Pick a fight

Denial• Flavor of month

Displacing responsibility• Attack authority• Kill the messenger• Scapegoat

What kinds of work avoidance / resistance have you seen in others?

What kinds of work avoidance have you seen in yourself?

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

Where We Are Right Now?

Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e


PRODUCTIVE RANGE

HOLDING ENVIRONMENT

Work avoidance

Work avoidance

Work Avoidance: A Signal

Technical challenge

Adaptive Challenge



Limit of tolerance

Time

Tens

ion

of c

hang

e

Resistance

A signal that you are losing influence and exceeding the amount of loss and uncertainty they can tolerate.How to respond:• Clarify your intentions.• Refine your approach to the tensions

between perspectives (conflicts) inherent in the issue.

• Try again to help the group make progress.

Passive or active


Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

Your Work



The Work


Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e

What people will not tell you, their behavior will reveal

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

Adaptive WorkYou

What does the work avoidance suggest?

How are those who care reacting to the work?

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.

Widen the zone of productive tension.

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

CONCEPTReflect in Action

Get on the Balcony and Dance

cI’m not getting my point across...Whatshould I say next?

Balcony AND Dance Floor

Over focus on Balcony Over focus on Dance floor

Professor Osmo Wiio: Laws of Communication

• Communication usually fails; except by accident.

• If a message can be interpreted in several ways, it will be interpreted in the manner that maximizes the damage.

• There is always someone who knows better than you what you meant by your message.

http://yle.fi/uutiset/professori_osmo_a_wiio_on_kuollut/6505579

“The single biggest problem with communication is the illusion that it has taken place.”

George Bernard Shaw

http://libapps.libraries.uc.edu/exhibits/irish-lit/twentieth-century-writers/

Be curious

Courtesy of Judy Brown

c

Mine Other’s

Intention

Impact

Other’s impact on me

My intention Intention of other

My impact

Harvard Negotiation Project

c

Mine Other’s

Intention

Impact

X

X


c

Mine Other’s

Intention

Impact

X

X

Our assumptions about intentionsare often wrong

Good intentionsdo not make bad

impact unimportantor irrelevant


c

Mine Other’s

Intention

Impact

This is what I meant

This is how it felt/seemed to me

Is that what you meant?

How did it feel/land with you?


cWhat they think they heard is much more important to the listener than

what you are sure you said.

The perception of the other is just as true as what you intended to say.

Practical Approach• Work closely with those

that offer resistance; they’re sending you a signal.

• Try to understand other people’s resistance to change.

• They may know something you need to understand!

What Do I Do Next?




Begin to Plot a Strategy• What do you need to do to make

progress?• What can you do to lower the

distress on those above the limit of tolerance?

• How can you maintain engagement of those currently engaged in trying to make progress?

• What can you do to raise the distress to a productive level for those below the level of learning?

c

Talk About It:

Think about a time when the heat was too high.

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

Lower the Heat

• Validate feelings; acknowledge loss.

• Simplify and clarify.• Restore, add, or reallocate

resources.

Talk About It:

Think about a time when the heat was too low.

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

Raising the Heat

• Raise the standards.• Increase accountability.• Change the task to something

more motivating. • Refocus on higher, more widely

shared, and compelling purpose.

PRODUCTIVE RANGE

HOLDING ENVIRONMENT

Work avoidance

Work avoidance

Technical challenge

Adaptive Challenge



Limit of tolerance

Time

Tens

ion

of c

hang

e

Are You Reading the Signals?Work avoidance signals being OUT of the productive zone

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

How to respond:• Clarify your intentions.• Refine your approach to the tensions

between perspectives (conflicts) inherent in the issue.

• Try again to help the group make progress.

Resistance Passive or active

Keep an Experimental MindsetExercising 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, then try the opposite.

Poll Question # 3Lowering The Heat

82

How do you lower the heat / bring things to a productive level of tension?

a) I validate feelings / acknowledge loss of the way things used to beb) I simplify and clarifyc) I restore, add, or reallocate resourcesd) All of the abovee) Unsure or not applicable

What Do I Do Next?




OPTIMAL STIMULATION Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e


Productive Range of Tension

What else would you add?

Optimal Stimulation• Work as a team. • Learn new ways to approach problems.• Create environments in which others can solve problems.• Help facilitate change in thinking and behavior.• Help the “light bulb” to go on.• Watch people transform while doing transformative work.• Help others gain confidence and feel energized by their success.

Resilient

Responsive

Apathetic

Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e


Overwhelmed

Productive Range of TensionZone of resilience and responsiveness

APATHETIC

OVERWHELMED

• I have a chance to work more effectively and efficiently

• I have a chance to constructively influence making care better

• I have a chance to learn improvement methods and skills to enhance my leadership

• I am asked to lead and I do not feel like I have enough authority to lead

• This is one more thing to juggle and I am already dropping the other things I am juggling

• My heart is not in it but I’m here• Standardization is cookbook medicine – I am

wasting my time

RESILIENTProductive Range

RESPONSIVE

Making Progress on Difficult Problems



Limit of tolerance

Time

Tens

ion

of c

hang

e

c

Strain of uncertainty

Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e


Strain of uncertainty; compressed adaptive capacity

Distressed System

“Can you endure your uncertainty until it shows you another way?”

Mark Nepo

“When nothing is sure, everything is possible.”Margaret Atwood

c

Strengthening Your Capacity to Tolerate

Uncertainty

c

Learn to not take it personallyEven when it is meant to feel personal

It’s Not Personal

95

People attack when you represent a message they do not like.• You are disappointing their

expectations at a rate they can’t tolerate.

When you take attacks personally you: • Conspire to take yourself out of the

action.

What You Do Next Matters

96

ReframePlace the focus back on the message and the issues.

Ask a question Your management of an attack (not substance of the accusation) determines your future effectiveness.

Use trusted colleaguesOthers can help you see what you have come to represent.


Don’t go it alone

Partnerships

Allies • Share some part of the

professional experience (has a competing interest).

• Care about the issue.

Confidantes • No competing interest.• Care about you.

Help you get on the balcony and see what you may have difficulty seeing.

Regain courage and perspective

Reaffirm a deeper sense of self and purpose

Restore spiritual resources

Feel physically and psychologically safe

Reflect and capture lessons

Find Sanctuary

“What boundaries do I need to put in place so I can work from a place of integrity and extend the most generous interpretations of the intentions, words, and actions of others?”

“I am going to be generous in my assumptions and intentions while standing solidly in my integrity and being very clear about what’s acceptable and what’s not acceptable.”From Rising Strong by Brene Brown, Random House, 2015, p. 123

Brene Brown

Common belief:Those who resist don’t care

Distressed System

Productive Range


Limit of tolerance

Time

Tens

ion

of c

hang

e


APATHETIC

OVERWHELMED

RESILIENT RESPONSIVE

Strain of uncertainty; compressed adaptive capacity

Predictable Fundamental Human Error of Attribution Others behave badly because of a character flawI behave badly when I am in a tough situation

Nobody behaves badly from a place of strength

Start with Compassion

When you don’t know what to try first, lower the heat.• Validate feelings; acknowledge loss.• Simplify and clarify.

• Address the technical aspects• Break the problem into parts

• Restore, add, or reallocate resources.• Temporarily reclaim responsibility for

tough issues• Give your attention• Take stock of what is available • Allot more time; enrich knowledge and

skills

Nobody misbehaves from a place of strength.

Give What You Need

• Empathy• Appreciation• Recognition• Honest feedback• Respect• A sense of connection to

meaningful work

• Validate feelings; acknowledge loss.• Simplify and clarify.• Restore, add, or reallocate resources.

Enhancing Resilience Raises the Threshold of Tolerance AND Lowers the Threshold (Enhances) of Responsiveness

Increased adaptive capacity

Lowered threshold for responsiveness

Raised threshold to continue to be resilient

Desired State: Increase Capacity for Adaptive Work

Time

Tens

ion

of c

hang

e


Widen range for holding tension of uncertainty productively

Activate and Expect Responsiveness Through Clear Boundaries

Raise the Heat:

• Raise the standards.

• Increase accountability.

• Change the task to something more motivating.

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

Build trust by doing new work togetherin new ways, equipping yourselves for resilience and responsiveness

Increase Capacity for Adaptive Work

Increased adaptive capacity

Lowered threshold for responsiveness

Raised threshold to continue to be resilient

Time

Tens

ion

of c

hang

e


Holding tension of uncertainty productively

Technical work• Clear answers, minimal uncertainty

• Straightforward, few big choices

• Execute via precise instructions

• Requires hands, feet, and mouths

• Focus on task

• Linear, demands precision

• Runs smoothly

Adaptive work• No clear answers, often high uncertainty

• Time consuming, difficult choices (losses)

• Demands lots of conversations

• Requires hearts, eyes, and ears

• Focus on people

• Demands creativity

• Conflict, distress, and fear

Leadership Challenges

New Insights?Technical Work vs. Adaptive Work

Poll Question #4

Adaptive WorkWhat percentage of your work is adaptive?

1) 0% to 25%2) 25% to 50%3) 50% to 75%4) 75% to 100%5) Unsure or not applicable

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.

• 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 yourself differently• Regulate distress• Widen the productive zone of

tension

Leading Adaptive Change

Lessons Learned at the Frontline• General relief when people understand the difference

between technical and adaptive work - and realize that something is not wrong with them because the work is hard.

• Lowering the heat does not mean letting people off the hook; it means giving people what they need to make progress.

• Understanding that the data itself tells a story.

• Need to start with believing people are doing what they are doing for a reason – be curious about intentions and don’t get distracted by impact.

• Speak to what brings people to healthcare and what keeps them in healthcare.

2 hours later…What do you see differently?Will anything be different in your approach to your work?

Analytic Insights

AQuestions &

Answers

117

What You Learned…

118

Write down the key things you’ve learned related to each of the learning objectives after attending

this session

Thank You

119

session 31 leading adaptive change to create value in

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