Fundamentals of Adaptive Leadership Val Ulstad MD, MPH, MPA

1. Fundamentals of Adaptive LeadershipVal Ulstad MD, MPH, MPA

2. Adaptive LeadershipBeliefs Behind Dr. Ron Heifetz’ work Problems are embedded within complicated and interactive systems. Much of human behavior reflects an adaptation to circumstances. People adapt more successfully to their environments by facing painful circumstances (aka FEAR) and developing new attitudes and behaviors.

3. Why Apply Adaptive Leadership in Health Care? • 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 clinicians

4. Opportunities Enhance capacity to exercise leadership Build a framework to help others make progress on tough problems Createresiliency to withstand the work of leadership

5. HumanSystems Limit of tolerance Tension of change Productive Range Threshold of learning Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

6. Type 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

7. Technical vs. Adaptive Work Limit of tolerance Adaptive challenge Disequilibrium PRODUCTIVE RANGE OF DISTRESS Tension of change Technical problem Threshold of learning Time Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

8. Adaptive Work Adaptive work diminishes the gap between the way things are and the way things need to be to create a better future

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

10. What is hard about leading others in improving care?

11. Properties of Adaptive Work Gap between aspirations and reality Tension between between points of view Difficult learning required Involves tolerating loss Perspective needs shifting New competencies must be developed People with the problem have problem solving responsibility Takes longer than technical work Requires experimentation Generates disequilibrium, distress and work avoidance

12. Adaptive Work 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

13. Technical and Adaptive • Fishbone diagram • Affinity diagram • Decision analysis tools • Measurement tools Technical pieces are necessary and insufficient for adaptive work

14. What is the work? Gap = difference between the way things are and the desired state Technical or adaptive? Hearts and minds need to change? Process of exclusion Persistence of conflict Crisis Where do we begin? Meaningful and Manageable

15. AIM Statement The work you are doing together Addresses a gap A big enough improvement target to be meaningful A contained enough project to be manageable Has key components Clearly articulated statement of intended improvement Aligned to organizational strategic focus Supports system quality or operations goals

16. Who Cares About the Work? Delivering high quality care with optimal stewardship of resources You Patient Other team members Family

17. Who cares about the work? Important stakeholders Team members Those affected by the change Those who support it Those who do not want to see it happen Project sponsor You Who else?

18. Limit of tolerance Productive Range Tension of change Threshold of learning Time Delivering high quality care with optimal stewardship of resources Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.

19. Adaptive Challenge Work Avoidance Limit of tolerance Productive Range Holding Environment Tension of change Threshold of learning Work Avoidance Technical Challenge Time Are you reading the signals others are sending? Work avoidance is triggered when the heat is too high or too low Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg. 108.

20. Work Avoidance Signals Being Out of a Productive Range of Tension • Displacing responsibility • Attack authority • Kill the messenger • Scapegoat • Distracting attention • Make the problem too big • Make the problem too small • Meetings with only information exchange when engagement and deep conversation is needed • Ask more consultants • Denial • Collude in magical thinking

21. Can you imagine some work avoidance examples you might see?

22. How are the people who care about the work reacting to it? Interpret Factional Stances: Is the faction above the limit of tolerance? Over the top Is the faction engaged in the work? Is the faction below the level of learning? Not my concern

23. How are you and others reacting to the work? What does the work avoidance suggest? Delivering high quality care with optimal stewardship of resources You

24. 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

25. Help People Make Progress on Adaptive Work Use yourself differently Create productive tension Keep people engaged who are making progress and figure out what you need to do to reengage others.

26. Authority ≠ Leadership

27. Authority • Power in exchange for service • A contract for service • Direction • Protection • Order • Formal and informal • A resource and a constraint on leadership

28. Informal Authority = Influence Power to influence beyond job description General credibility and professional reputation Implicit expectations Critical source of leverage for formal authorities too

29. Think of a time when you told people what they needed to hear rather than what they wanted to hear. What happened?

30. Exercising leadership to do adaptive work means disappointing people’sexpectations at a rate they can tolerate.

31. 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 muzzle you)

32. Leadership is an activity There can be leadership from multiple positions within a social structure

33. Get on the Balcony Fundamental Skill in Adaptive Leadership Reflect in action Keep the pattern of the dance in mind while dancing Move back and forth

35. Use Yourself Differently Exercise leadership and use your informal authority as a resource Reflect in action – get on the balcony Set a great example Celebrate and learn from what is going well Talk about why you think this is important Ask questions Listen Pay attention

36. Behaviors That Build Trust Talk straight Demonstrate respect Create transparency Right wrongs Show loyalty Deliver results Get better Confront reality Clarify expectations Practice accountability Listen first Keep commitments Extend trust Adapted from The Speed of Trust, Stephen M.R. Covey, 2006.

37. Create Productive Tension Make it safe to disagree and debate but not OK to opt out and disengage. Talk honestly to one another about the challenge Listen with genuine interest to the various points of view Build trust Have difficult conversations

38. Difficult conversations are inevitable Safety is critical for them to be productive shared purpose mutual respect Be willing to be influenced Be curious rather than judgmental 100% candid 100% respectful Lead with questions not answers Engage in dialogue and debate not coercion

39. Create an Environment to Hold Attention on the Work Limit of tolerance People need to feel safe enough to do adaptive work but not so safe that they will do nothing. Productive Range Tension of change Threshold of learning Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg 108.

40. Distressed System No Trust, Little Adaptive Capacity Limit of tolerance Tension of change Productive Range Threshold of learning Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002.

41. What is a difficult conversation? • Any conversation that you dread and perhaps seek to avoid, if possible • Three inherent challenges present the source of difficulty • There are inevitably more ways to understand the situation than any one participant is aware of or agrees with • The situation is emotionally charged with strong feelings • The situation is psychologically threatening to one or both parties

42. Which Condition of Safety is at Risk? • Mutual purpose or mutual respect • Conditions make the conversation difficult • much more than content AdaptedfromCrucialConversations

43. Shared Vision Delivering high quality care with optimal stewardship of resources Limit of tolerance Tension of change Productive Range Threshold of learning Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

44. How Do We Hold the Tension? Delivering high quality care with optimal stewardship of resources – respectfully? Limit of tolerance Tension of change Productive Range Threshold of learning Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108. and adaptationfrom Crucial Conversations

45. Widening the Productive Range • Conditions of safety • Mutual purpose • Do others believe you care about their goals in the conversation? • Do they trust your motives? • Mutual respect • Do others believe you respect them? Adapted from Crucial Conversations

46. Increased Trust, Increase Capacity for Adaptive Work Limit of tolerance Tension of change Productive Range Threshold of learning Time Based on Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA,2002, pg. 108.

47. Keep people engaged who are making progress and figure out what you need to do to reengage others.

48. Adaptive Challenge Work Avoidance Limit of tolerance Productive Range Holding Environment Tension of change Threshold of learning Work Avoidance Technical Challenge Time Work avoidance signals being out of a productive zone relative to the work Work avoidance is triggered when the heat is too high or too low Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, Boston, MA, 2002, pg. 108.

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

50. Lowering the Heat • Validate feelings, acknowledge loss • Simplify and clarify • Address the technical aspects • Break 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