“Standard work” for leaders includes being involved and practicing a style of management that includes coaching, mentoring and teaching rather than just commanding, expecting, and holding accountable the people who do the work. John Toussaint has postulated that sustained success with Lean requires organizational transformation. He believes that the movement from “doing Lean” to “being Lean” cannot occur without the transformation of senior leadership. Lean must become the operating system that bridges “silos” to allow the breakthrough improvements that can be achieved when management moves from functioning through pure “authority” to being actively involved in the transformation to an organization capable of producing sustainable value.
Thomas Rice follows my “Healthcare Musings” and recently sent me his review of a new book on leadership. For The Common Good; Redefining Civic Leadership, by David Chrislip and Ed O’Malley. Their book advocates for a form of more active leadership. The authors elegantly trace the short history of the academic analysis of management and leadership. They follow the evolution from the “big man” concept of leadership, through situational leadership and less explicitly toward “level five leadership” and “servant leader” models.
In earlier discussions of Lean leadership my intent has been to position it as an even more evolved state of leadership than “level five leadership” or the “servant leader” model. Compared to any other model, Lean leadership has moved further past the use of authority and further down the path of actively engaging people as leaders at all levels of the enterprise. A successful Lean enterprise disperses authority and creates opportunities for leadership and facilitates the development and deployment of strategy up and down the organizational structure. Inviting others into the roles of strategist, problem solver, improver, innovator and “silo bridger” are core behaviors of the Lean leader. Knowing how to build the relational contracts and foster the trust that accompanies those invitations to become strategists, problem solvers, improvers, innovators, and “silo bridgers” are key competencies of the Lean leader.
The authors share my belief that leaders can be made and will spontaneously appear when given the chance. I have seen people emerge as newly minted leaders during a Kaizan event or when challenged in the evaluation of a value stream. Lean methodology creates a learning lab for leadership that multiples the organization’s capacity to respond to the needs of patients and the external challenges of our times.
The book corroborates many of my own feelings and has contributed to my hope that by enlarging and continuously transforming our concepts of leadership in ways that are consistent with Lean leadership, we will accelerate our ability to process change and achieve our Triple Aim goals. Thomas’ words support my hope.
For The Common Good; Redefining Civic Leadership, by David Chrislip and Ed O’Malley….is a direct challenge to an orthodoxy that has dominated a field that was first established as such in the late 60s and 70s. Even a casual review of this daunting body of work cannot fail to notice that, for all its variety, there is one dominant carrying beam, a mostly-unspoken premise, at the center of this literature: Leadership resides in the individual in a position of authority with a followership dependent on the leader for vision, strategy, and inspiration. Sometimes charismatic, often not, the leader is always at the center of the action. His character and intellect—and it is typically a man —is the main determinant of the fate of his followers, be they organizations, cities, regions, or nation states…Others have broken with this “great man” theory before, but no one I’m aware of has prosecuted the case so explicitly, with such theoretical elegance and empirical clarity…
The concept that leadership is confined to an individual posited with “authority” has been challenged in many ways. People like the authors and also many in Lean like John Toussaint are arguing that leadership needs a new model with new objectives and a broader base. Their insights are replacing the “great man” model. The book and Thomas’s review are another take on Toussaint’s concept of the problematic limitations of “Sloan Management” or “top down” use of authority to direct the enterprise. The book traces the evolution of leadership theory and practice over the last 60 years and comes to the conclusion that focused authority in one or a few individuals who theorize and then direct the efforts of others is a process with a limited arc of success. The old leadership styles are not adequate for our complex times and the interconnected problems and opportunities that exist in the volatile, uncertain, complex, and ambiguous world that we call home.
[The book]..is not just an inspirational statement on why this new model of leadership is imperative, but also a highly accessible theoretical framework that has already passed the practitioner’s test in the field. The result is an exemplary act of civic leadership worthy of Gandhi’s adage that “…we must be the change we want to see in the world.”
In the mid nineties I was introduced to the work of Peter Senge and others who were talking about the “learning organization”. The description of the “learning organization” was an attractive alternative to the “top down” style of leadership that the physicians of the “staff model” practice of Harvard Community Health Plan had come to experience. Even more than twenty years ago there was a sense that with each new year we were delivered an order for yet more productivity that would require running harder with less and less local say in how we achieved those goals. Leadership set the direction and the goals (management by objective) and then issued the command to go forth and accomplish those goals without much additional help or advice.
At about the same time I also read Charles Handy’s paper on federalism from the Harvard Business Review. The concept of local control and the idea of subsidiarity seemed to me to be totally consistent with the concept of the “learning organization” and together they constituted a significant argument against the command and control environment that we were experiencing as each year upper management translated the external pressures coming from the marketplace into new demands that the practice had to meet and exceed. The tools that evolved were more oriented to volume than to quality and value. At a time when the IHI was emerging with a focus on safety and quality we were obsessed with market share and the bottom line. It felt like we had lost all of our internal values. We did not know where true North was.
The demands of management placed clinical values in a subservient position to business concerns and eventually led to the emergence of a “coalition of the concerned” that spawned a lot of grassroots leadership. The result was several years of tension and negotiations that eventually led to the creation of Harvard Vanguard Medical Associates on January 1, 1998. The progress toward our utopian world was torpedoed by the financial collapse of Harvard Pilgrim at the end of 1999. Almost instantly we lost at least 150,000 patients. We were in trouble just as we were beginning to make progress on a core objective, which was to diversify the source of our patients by moving from being an exclusive offering of Harvard Pilgrim to accepting patients from all payers.
Our grand experiment in local control died as we shifted to survival mode and returned to the standard management structure of the “big man” leader who is empowered to manage top down. Collaboration across departments and sites was replaced by hoarding of resources within specialties and service lines. We entered a new world of fee for service where the credo was “eat what you kill”. Each individual was valued or not based on their monetary contribution. The glaring unfairness of how the external world distributes reimbursement created problems for some specialties. Everyone had to generate enough surplus to pay off the center and survive on the residual. The operative phrase was “everyone on their own bottom”. Some departments like Behavioral Health never had a chance to even cover their own direct costs because of the low reimbursement for their services. After a long discussion, they became the recipients of the charity of the collective.
After our initial attempts at “do it yourself Lean” and experiments in clinical improvement funded by Blue Cross, we restarted our Lean journey in 2009 with Simpler as our partner and guide. We chose Simpler because of their results with the IHI, ThedaCare and Denver Health. I soon discovered that the principles we were learning reversed our “top down” management. With Lean’s focus on respect for those who are doing the work and with a desire to create value we were once again a learning organization. Lean took us back to the principles of local involvement and control in an enterprise that respected subsidiarity and moved us toward a form of “distributed leadership” that created many active leaders. Lean gave us hope that we could manage the challenges that would surely come our way if our predictions came true that we would feel a downward pressure on revenue with rising internal costs as health reform evolved in Massachusetts.
Thomas continues by saying:
… the book begins with a “foundational essay” that lays out the history of thinking about civic leadership in the U.S., including a linkage to the four great social movement dating back to the 60s and 70s: civil rights, grassroots, environmental, and women’s—all with common themes which “…threatened traditional power structures, radicalized and mobilized unheard of or disenfranchised voices and, at times, menaced the country with anarchy when institutions failed to change …”
The parallels between what the authors describe and what has happened at Harvard Vanguard was not lost on me. In the “foundational section” the authors review adaptive change and suggest that the most important new competency for leadership is an understanding and ability to manage adaptive change.
They pass on the thesis of Heifetz and Linsky that solving complex problems that are an adaptive challenge requires recognizing that:
- Solutions lie outside our current way of operating.
- Solutions require learning.
- Solutions require a shift of responsibility from authority to stakeholders.
- Solutions require what is precious and what is expendable.
- Solutions demand experimentation.
- Solution requires time frames longer than we are accustomed to.
That list sounds to me like the challenges of adaptive change requires Lean and leadership that knows how to use Lean. The change that is needed exceeds the capacity of the “traditional 20th century paradigm of top down, hierarchical, authority-centered leadership”.
The authors also advocate something similar to a PDSA cycle introduced as dependent on four competencies that sound like standard work for Lean leaders.
…four competencies follow from the guiding principles. They rely on citizen activists’ ability to: diagnose the situation, manage the self, intervene skillfully, and energize others.
Core to Lean leadership is an ability to complete the “I to We transition” or as Thomas says it:
The book closes by coming full circle to a spirited advocacy: a shift from individualistic thinking to a “much more appropriate view for the 21st century…leadership as sharing responsibility for acting together in pursuit of the common good”
Within that description and within a Lean culture there is a compelling need for the creation of a host of problem solvers and an army of committed leaders distributed through every level of the organization. Thomas says the alternative is:
We could, of course, continue to play the waiting game, cynical bystanders one and all, waiting for a charismatic hero to gallop to the rescue, only to dash our hopes all over again…
