In pursuit of the Triple Aim, healthcare leaders work hard to improve care, reduce costs, and improve the patient experience. But accomplishing these goals requires an engaged staff that makes progress, day in and day out. Adaptive Leadership (AL) principles help leaders understand human behavior to mobilize change and overcome work avoidance, which happens when staff operate above or below the productive zone of tension. By understanding what adaptive work actually is (and that adaptive problems can’t be solved with technical fixes), and why work avoidance happens (because people are overwhelmed; the heat is too high), leaders can keep their teams engaged by using influence and leadership—not authority—to “lower the heat” on their people: Validate the difficulty of the situation. Simplify/clarify the work. Provide additional resources (time, training, etc.) Dr. Ulstad has worked with healthcare leaders and teams for the last 20 years to help them understand behaviors triggered by rapid, high-volume change, and apply AL principles to guide the changes critical to their organizations’ success.

1. Leading Adaptive Change to Create
Value in Healthcare ̶ Dr. Val Ulstad
MD, MPA, MPH

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Mobilizing Others to Learn and Innovate
You’re trying to make things better.
You’re working hard to improve care,
reduce costs, and improve patient
satisfaction—the goals of the Triple Aim.
You can’t make people do this work but
must help them take up the work.
Adaptive Leadership means:
Mobilizing others to learn and innovate to
make progress in addressing the gap
between the way things currently are and
the desired state you are striving toward.

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Mobilizing Others to Learn and Innovate
Adaptive Leadership maps the territory of
human behavior, helping leaders
understand what people do and how they
behave when faced with change.
Adaptive Leadership is a leadership
language and conceptual framework that
Dr. Ron Heifetz developed to help
individuals thrive amidst uncertain change.
He created this way of understanding
human behavior and mobilizing
meaningful progress for leaders trying
to bring about change in the world.

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Mobilizing Others to Learn and Innovate
Heifetz used his living laboratory, the Mid-
Career Master of Public Administration Program
at Harvard University’s Kennedy School, to
develop this language and approach.
Harvard’s Kennedy School is a school of
public service that attracts professionals
from around the world to learn and reflect
on their work.
It’s where I met and studied with Heifetz and
realized that this way of looking at group
dynamics and human behavior was a key
capacity needed in healthcare leadership.

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Recognize Adaptive Work
There are two types of challenges:
Technical & Adaptive
With technical problems, the ability to solve
the problem already exists within the system
and needs to be applied.
With adaptive problems, people deeply and
broadly within the organization/community
need to learn new capabilities, and hearts and
minds as well, as behaviors must change.
Adaptive work diminishes the gap between
the way things are and the way things need to
be to create a better future.

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Recognize Adaptive Work
The most common cause of leadership
failure is treating an adaptive problem
with a technical fix.
Technical fixes are not bad, and may
be part of the solution, but are
insufficient for adaptive work.
When we treat adaptive work with
technical fixes the problem keeps
coming back, again and again

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Recognize Adaptive Work
Improvement in quality and safety outcomes of patient care.
Clinical and non-clinical healthcare service delivery process
improvement.
Enhancement of interdisciplinary and multi-professional
teamwork through collaboration on improvement initiatives.
Reduction of waste and minimization of variation in processes.
Enhancement of organizational learning through shared
knowledge of best practices based on improvements.
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There are several examples of adaptive work:

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Recognize Adaptive Work
Why are these adaptive problems?
There is tension between multiple
perspectives, difficult learning is required
that necessarily involves loss and letting
go of the known past.
As the unknown future is created, the
stakeholders have problem-solving
responsibility and there is no quick fix.
Experimentation is required. People
get scared and overwhelmed, and
resist change.

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Recognize Adaptive Work
Budgets are another example of adaptive work;
they seem technical—just math problems.
Why, then, is everyone so tense at budget time?
Difficult discussions, tradeoffs, and
disappointments happen at budget
time: this is the adaptive work.
Generating data is technical work but
using data to have conversations about
care and building collaboration to improve
and transform is adaptive work.

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Exercise Adaptive Leadership with Influence—
Not Just Authority
Having authority, whether formal (a job
description or title) or informal (through
influence), is necessary but insufficient to
the effective exercise of leadership.
Having authority, power, or influence alone
doesn’t guarantee leadership.
Leadership is an activity that mobilizes
others to do adaptive work: it helps others
see what they need to do and supplies
them with the tools and feedback they
need to make progress.

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Exercise Adaptive Leadership with Influence—
Not Just Authority
Formal authority (command and control) is
sufficient for technical work.
Constructive influence is required for adaptive
work—formal authority is insufficient. How one
uses authority is key.
The exercise of leadership requires profound
clarity about what the work actually is, a
clear understanding of the current state and
characteristics of the desired future state.

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Exercise Adaptive Leadership with Influence—
Not Just Authority
Adaptive leadership is the ability to hold
people’s attention on the work at hand,
tolerate ambiguity and allow emergence.
It is keeping tension relative to the work at a
productive level over time, and constraining
the system enough so people feel held but
not too tightly.
It’s a willingness to hold loosely enough
to allow for emergence of new ways of
working required to make progress on
adaptive work.

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Exercise Adaptive Leadership with Influence—
Not Just Authority
Exercising leadership to do adaptive work
means disappointing people’s expectations
that things will stay the same at a rate they
can tolerate, without them ignoring you,
trying to silence you, or resist you in
infinitely creative ways.
Leading in this way means trying things,
observing what happens as a result,
and trying again.

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What People Won’t Tell You, Behavior Will Reveal
Energy, tension, and stress are necessary
for progress. People need the right amount
of tension—a productive range of tension
and energy (not too much or too little)—so
they can engage in and own their work.
A productive amount of tension helps build
their confidence and sense of effectiveness.
An upper limit of tension (limit of tolerance)
exists, above which an individual does not
function well relative to the work and begins
to behave in ways that reveal distress.

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What People Won’t Tell You, Behavior Will Reveal
Similarly, there is a lower limit (threshold of
learning), below which an individual doesn’t
function well relative to the work and begins
to behave in ways that reveal that.
If tension is too high, people feel
overwhelmed; too low and people feel
apathetic and unengaged.
When people are within the productive
range of tension, they can work with
optimum creativity.

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What People Won’t Tell You, Behavior Will Reveal
The challenge in leading adaptive change is
to keep in the productive zone of tension as
much as possible and create a culture of
respect and honest dialogue that helps
widen that zone.
People’s behavior will tell you when they
are out of the productive range.
Adaptive leadership is learning to read
those behaviors and be willing to try, fail,
and try again, to help get them back into a
productive range so progress can be made.

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What People Won’t Tell You, Behavior Will Reveal
When the work at hand is adaptive, resistance
shows up when people are overwhelmed or
disengaged from work.
Behaviors will always reveal when people are
outside the productive zone.
“THIS ISN’T MY PROBLEM.”

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Start By Lowering The Heat to Bring People Back
The challenge in the exercise of leadership is
that the behavior looks the same both above
and below the productive zone.
Heifetz uses the metaphor of heat:
ABOVE LIMIT OF TOLERANCE
BEHAVIORS
BELOW LIMIT OF TOLERANCE
BEHAVIORS
Displacing responsibility
Distracting attention
Denial
Displacing responsibility
Distracting attention
Denial

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Start By Lowering The Heat to Bring People Back
When work avoidance (resistance) shows up, it
is a signal that you are losing influence.
A person exercising adaptive leadership must
then decide what to try next to bring the person
back into productive engagement with the work.
It is critical to understand that either situation
can result in identical avoidance behaviors.
Our usual assumption is that resistance means
people don’t care and should be pushed harder.
In reality, this usually makes things worse.

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Start By Lowering The Heat to Bring People Back
When exercising leadership, learn to read work
avoidance as a sign you need to try something
to bring people back into the work.
When you meet resistance, try lowering the heat
by validating the difficulty of the situation or by
simplifying and clarifying the work.
Break the work into steps or provide or
resources like your attention, time, or training.
At first, it can seem like lowering the heat means
taking somebody off the hook, but you are
actually trying to get them back in the game.

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Start By Lowering The Heat to Bring People Back
Most of the resistance you see means the heat
is too high. Lowering the heat is compassionate,
builds relationships, and gets results.
In exercising leadership to make progress on
adaptive problems, a person must be able to
step back, stop the action for a moment, and
assess what is taking place.
Leaders must open themselves to multiple
possibilities, widen their set of diagnostic
options, test their interpretations, take
action, and reflect on the results of change.

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Start By Lowering The Heat to Bring People Back
Applying the fundamental principles and
practices of AL can enhance your ability to
effectively work with others by seeing
human behavior differently and making
sense of the behaviors triggered by rapid,
high-volume change.
Through genuine engagement and
transparent (yet accountable) decision-
making processes, you can guide and
drive the changes critical to your
organization’s success.

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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More about this topic
Link to original article for a more in-depth discussion.
Leading Adaptive Change to Create Value in Healthcare
5 Principles of Adaptive Leadership and Why It’s a Critical Skill for Healthcare Leaders
Dr. Val Ulstad, MD, MPA, MPH
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6 Proven Strategies for Engaging Physicians—and 4 Ways to Fail
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Dr. Bryan Oshiro, Chief Medical Officer, Senior VP; Dr. John Haughom, Senior Advisor;
Sherry Martin, Director

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Val Ulstad, MD, MPA, MPH, brings over 25 years of academic and private cardiology practice,
physician leadership experience, and award-winning teaching skills to her current role as an
educator in independent practice and a process consultant, emphasizing leadership capacity
building in healthcare. Refocusing a life of “heart work” toward the challenge of facilitating human
development, she now works deeply and broadly within organizations and teams to catalyze
transformative change.
She is a Distinguished Alumna of the University of Minnesota’s Medical School and a recipient of the Minnesota
Medical Foundation’s Lifetime Distinguished Teacher Award. In 1996, she was awarded Archibald Bush
Foundation Leadership and Medical Fellowships. She used her awards to support obtaining additional training
and graduated with honors from the University of Minnesota School of Public Health and from the Kennedy
School of Government at Harvard University, where she was a student of Dr. Ron Heifetz and was named a
Lucius N. Littauer Fellow for distinction in academics. Val is a certified coach of the Hudson Institute of Santa
Barbara and a trained facilitator for the Center for Courage and Renewal, which promotes the work of Parker
Palmer and the Circles of Trust approach. With her life and work partner (Partners at Cascade Bluff, LLC) of
over 30 years, she has built an off-the-grid home in far northern Minnesota where they spend half their time.
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