Leading Adaptive Change: A Framework to Transform Healthcare

© 2014 Health Catalyst
www.healthcatalyst.com
Proprietary and Confidential
www.healthcatalyst.comProprietary and Confidential
Val Ulstad MD, MPH, MPA
Leading Adaptive Change

Proprietary and Confidential 2

Why Adaptive Leadership?
• 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 organizational citizen
• Really resonates with professionals in
health care

Adaptive Leadership
Work of Ron Heifetz, M.D.
People adapt more successfully to their environments
by facing painful circumstances and developing new
attitudes and behaviors.

Productive Range
Threshold of learning
Limit of tolerance
Time
Tensionofchange
CONCEPT #1
Productive Range of Tension
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press,
Boston, MA, 2002, pg 108.

Productive
Range
Limit of tolerance
Time
Human Systems
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.
I understand the reality of my condition.
I am looking to you for guidance and honesty.
I understand what I need to do.
I don’t want to hear any more bad news.
I can’t make sense of any of this.
I am so terrified I don’t understand a
word you are saying.
I came for a pill or gadget to fix this.

Productive
Range
Limit of tolerance
Time
Human Systems
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

CONCEPT #2
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

Address the Gap Between
The Way Things are
and Achieving the Triple AIM
Improved Health of the Population
Enhanced Patient Experience of Care (not
forgetting the experience of the people who provide it)
Reduce (or at least control) Total Cost of Care
The Challenge

Properties of an Adaptive Challenges
Wicked Problems
•Gap between way things are and desired state
•Varied points of view
•Requires difficult learning
•Involves facing loss
•New competencies must be developed
•People with problems have problem solving responsibility
•Takes longer than technical work
•Requires trying things
•Generates disequilibrium, distress and work avoidance

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

Question #1
What is the work?
Gap = difference between the way things
are and the desired state
Start somewhere meaningful and
manageable

Adaptive Work
Diminishes the gap between the way
things are and the way things need to
be to create a better future
Adaptive leadership is the activity that
mobilizes people to perform needed
adaptive work

Adaptive Work
You
Question #2 Who Cares About the Work?

Organizations are illusions; they
are just groups of relationships
- Parker Palmer

When you
consider Lincoln,
did he embody -
Authority?
Leadership?
Both?

Authority Leadership
• Leadership is an activity
• Authority, power and influence are tools
but do not guarantee leadership
- necessary but insufficient

CONCEPT #3
There is a difference between the role
of authority and the exercise of
leadership.

Authority
(whether formal or informal)
is necessary
but insufficient for the
exercise of leadership.
Ability to constructively
influence
is a
critical resource for leadership
even when/if you have a big title.

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

Your Success at Influencing
Another
•Their capability to do what you ask
•Plus +
• (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
Perception Matters
You will tend to over
focus on
● Potential gain to
other
● Extent to which
you are trusted
Other will tend to over
focus on
● Potential personal
risk
● Potential personal
cost
Adapted from The Shifting Sources of power and Influence
– Dr. Charles E. Dwyer

Emotional Bank Account
Adapted from S. Covey Sr., Seven Habits of Highly Effective People, Simon and Schuster, 1999
Esteem
Acceptance
Respect

Emotional Bank Account Balance Sheet
Courtesy
Kindness
Honesty
Keep commitments
Discourtesy
Disrespect
Interrupting
Overreacting
Causing another to feel ignored
Becoming arbitrary
Betraying trust
Threatening
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 commitments
• Clarify expectations
• Personal integrity
● Walk your talk
● Be loyal to those not present
• Sincerely apologize when you make a “withdrawal”

People 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
Constraints of Authority

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

Resistance
(passive or active)
• A signal that you are losing influence
and are exceeding the amount of
loss and uncertainty they can
tolerate.
• Clarify your intentions
• Refine your approach to the tensions
between perspectives (conflicts)
inherent in the issue
• Try again to help the group make
progress

Productive Range
Limit of tolerance
Technical
challenge
Time
Making Progress on Work
Adaptive Challenge
Tensionofchange
Based on R. Heifetz and M. Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

Productive Range
Limit of tolerance
Time
Tensionofchange
The Work
Distress
Distress

Productive Range
Limit of tolerance
Time
Tensionofchange
The Work
What People Will Not Tell You, Their Behavior Will Reveal
Blame others, distract attention, denial
Blame others, distract attention, denial
Distress
Distress

CONCEPT #4
Work Avoidance as a Signal of Being Outside
the Productive Range of Tension
37

Work Avoidance
(Resistance)
• Displacing
responsibility
• Attack authority
• Kill the messenger
• Scapegoat
• Distracting attention
• Pretend to be busy
• Define problem to fit your
competence
• Make the problem too big
• Restructure/reorganize
• Meetings with only information
exchange when engagement is
needed
• Pick a fight
• Denial
• Flavor of month?

Work Avoidance (Resistance)
• Displacing
responsibility
• “The rest of my team
is incompetent”
• “Our coach is not
doing their part.”
• “This is a passing
fad – the leaders
don’t really want
this”
• Distracting attention
• “This cookbook medicine!”
• “This all about money not
care.”
• “I am too busy – I have a day
job”
• “I can’t ask my colleagues to
do that!”
• Excuses for missed meetings
• “I am losing income to do this
work”
• Denial
• “This work will not change
anything”
• Not showing up
39

PRODUCTIVE RANGE
HOLDING ENVIRONMENT
Work avoidance
Limit of tolerance
Technical
challenge
Time
Adaptive Challenge
Work avoidance
Tensionofchange
Are You Reading the Signals People are Sending You?
Work Avoidance Signals Being Out of Productive Zone

Resistance/Work Avoidance
When people resist the change you are helping them
face and avoid the work – which of the following is
true?
a. It can mean they just don’t think the issue
requires their involvement
b. The rate of change is too much for them to
tolerate
c. It can mean they are overwhelmed and don’t
know what to do next
d. It means you need to try a new “test of change”
e. All of the above
41

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 Work
You
Question #3 How are the people who care about
the work reacting to the work?
What does the work avoidance suggest?

Which statement best represents how you
are feeling?
Choose one
1. I feel like I’m taking a drink from a fire hose;
I’m overwhelmed
2. Seems like good common sense to me; I’m
with you, keep going
3. This really doesn’t apply to me ; I’m not in
charge, so I’m not sure I need this
46

Productive Range
Limit of tolerance
Time
Tensionofchange
Where We are Right Now
Based on R. Heifetz. and M. Linsky. Leadership on the Line, Harvard Business School
Press, Boston, MA, 2002, pg 108.
Taking a drink from a fire hose
Overwhelmed
Seems like good common sense to me
I‘m with you, keep going
This doesn’t really apply to me
I’m not in charge, I don’t need this

Question #4
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.

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

CONCEPT #5
Reflect in Action
Get on the Balcony and Dance

Balcony AND Dance Floor
Over focus on Balcony Over focus on Dance floor

What do you need to do to make progress?
What can you do to lower the distress on the factions that are
above the limit of tolerance?
How can you maintain engagement of factions that are currently
engaged in trying to make progress?
What can you do to raise the distress to a
productive level for the factions below the level of
learning?
Begin to Plot a Strategy

Think about a time when
the heat was too high.
What did you do to bring things to a
productive level of tension so progress
could be made?

Lower the Heat
• Validate feelings; acknowledge loss
• Simplify and clarify
• Restore, add or reallocate
resources

Think about a time when the
heat was too low.
What did you do to bring things to a
productive level of tension so
progress could be made?

Raising the Heat
• Raise the standards
• Increase accountability
• Change the task to something
more motivating
• Refocus on higher, more widely
shared and yet compelling
purpose

Resistance
(passive or active)
• A signal that you are losing influence
and are exceeding the amount of loss
and uncertainty they can tolerate.
• Clarify your intentions
• Refine your approach to the tensions
between perspectives (conflicts)
inherent in the issue
• Try again to help the group make
progress

Exercising 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 try the
opposite.

Nobody misbehaves 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
o Address the technical aspects
o Break the problem into parts
• Restore, add or reallocate resources
o Temporarily reclaim responsibility for tough issues
o Give your attention
o Take stock of what is available
o Allot more time, enrich knowledge and skills

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

Leading Adaptive Change
Four Questions
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 your self differently
- Regulate the heat

Technical vs. Adaptive work
Clear answers, minimal
uncertainty
Straightforward, few big
choices
Execute via precise
instructions
Requires hands, feet, mouths
Focus on task
Linear, demands precision
Runs smoothly
No clear answers, often high
uncertainty
Time-consuming, difficult choices
( losses)
Demands lots of conversations
Requires hearts, eyes and ears
Focus on people connected to
task
Spiral with feedback loops,
demands creativity
Conflict and distress
64

Thank you!!
65

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