Leading complex change: go slow to go fast
Michael Gardam, MD, and
Leah Gitterman, MHSc
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In this article, we bring a complexity science perspective to health care leadership challenges, using hospital mergers as an example. In this case study, we draw heavily on our own experience working with organizations struggling with change. Unlike the traditional top-directed approach, we recommend starting slowly and engaging those affected by the coming changes to enable co-creation of the eventual solution.
KEY WORDS: change management, complexity approach, staff engagement
You have just been hired as medical director of a large clinical program that is delivered at two acute-care hospital sites. The two hospitals have recently been merged, and the mandate of the new leadership team is to “streamline and harmonize” clinical activities across your program to eliminate redundancy and improve quality. You have been brought in from another organization as a “neutral third party.” Top
During merger discussions, it became clear that one site, which is the larger of the two, seemed to have a relatively well-functioning care delivery model based on reported metrics. It is hard to say how well the smaller site’s program is functioning as it does not use similar measures; however, the physicians tell you the program is well designed to meet the needs of its patient population. You have called together team members from both sites to a meeting to discuss next steps.
A traditional approach
In our experience, the above scenario is common in Canadian health care. In the name of efficiency and economies of scale, provincial governments may require organizations or even health regions to merge. Physicians representing the smaller hospital likely fear what might be coming next: namely, that they will be forced to adopt the practices of the larger site. After all, the program at that site is larger, more sophisticated in the use of metrics, and appears to be doing well. Conversely, physicians at the larger hospital may be feeling more secure, sensing that their program model is likely going to be preferred. Top
Imagine how this scenario might be even more challenging: what if the two hospitals were well-known competitors or if the merger were between an academic centre and a local community hospital? A well-traveled path suggests that you, as the leader, should gather as much information as possible from each of the programs and perform some strategic analysis to arrive at options. With this information in hand, you will then be able to make firm decisions, seek buy-in to your plan from physicians and other team members by communicating your message and rallying them around a burning platform for change, and then act on merging the programs.
This planned-out way forward, first described by Kotter1 four decades ago appears both straightforward and logical; yet we know that most change initiatives fail to meet their original goals.2 In our experience, one common reason for failure involves treating a problem as a simple one, for which solutions can be planned and executed, when it is in fact complex. In the world of complexity science, a complex problem is defined as one for which there is neither agreement on the best solution, nor any certainty that any one solution will be successful.3 Top
Thinking in complexity terms requires a shift away from focusing on the parts of the system toward the interactions of the components and people within the system. This distinction matters because the tools and approaches used to successfully tackle complex problems are often counter to prevailing health care culture which tends to be top-down directed.
A complexity perspective
In the above example, is the selection of one program’s model over the other necessarily the best way forward, i.e., does the future program have to be either/or? We suggest there is another way forward that accepts, rather than downplays, the complex nature of the merger. This will undoubtedly mean that the way forward will be far less clear at the outset and will be more uncomfortable for you as the leader. Top
Why would we suggest such an approach? As Karen Phelan4 in her book, I’m Sorry I Broke your Company, explains:
We have been led to believe… that businesses are logical and run by the numbers and that their models and theories will provide step-by-step instructions on how to succeed. But businesses are people — irrational, emotional, unpredictable, creative, oddly gifted, and sometimes ingenious people who don’t operate according to the theories.
An inconvenient reality about leading complex change initiatives is that they involve people, not robots or cogs in a machine. People, even highly trained physicians, react emotionally to change, and especially to change being forced on them. People being asked to “buy-in” to a change that they had no role in designing will typically push back, drag their feet, use other ways to delay or derail it, or simply quit their positions. They may also tell you why your plan will not work and how they are different from other groups. Top
Another inconvenient fact is that they may well be right: as the people working in their area day after day, they have accumulated detailed knowledge and insight that a leader is unlikely to have.5 Their knowledge is more than just the metrics; it is an understanding of the unique social networks and personalities that make their group function.
Medical staff have additional, valid reasons for resisting change. We are trained to be cautious, which, while undoubtedly protects patients from untested approaches, also tends to make us more comfortable with incremental change rather than creative destruction and rebuilding. Furthermore, unlike most administrators and other health care professionals, those of us practising in a fee-for-service model may feel a direct impact on our income as a result of changes to organizations and processes. In addition, those dependent on billing income will understandably find it difficult to become heavily engaged in a change process, as they may have to lose income to participate.
Of course, the fact that the two merging organizations do things differently and have distinct cultures is not unique to the medical staff. For every reluctant doctor, there are likely many more apprehensive administrators and front-line staff who also fear the merger. Top
Some early first steps
Although the ultimate look of the program is not yet knowable, we can plan some initial steps. Change in complex adaptive systems can occur through seemingly small tweaks to parts of the system, with special focus on the relations between the parts.6 Thus, we suggest that the next step is to sit down with team members and engage them in discussion regarding the key overarching goals or “minimum specifications” of the future program and set boundaries for what is in and out of the scope.6,7
We further suggest that the team does not mean just medical staff: we would invite all team members who are “touching the problem,” including carefully chosen patient and family representatives.
Rather than a traditional brainstorming session during which, in our experience, most participants may remain silent, we would use simple engagement techniques termed “liberating structures” to hear from all members of the group.8 One of our favourite liberating structures is called “What, so what, now what?” which forces the group to pause after information gathering and fully explore the situation at hand before moving on to action. Top
The importance of diverse opinions
Especially early on in the change process, the leader needs to hear the diverse opinions of the team. In our experience, this is one of the most frequent stumbling blocks in leading change initiatives: in the interest of moving a project forward, leaders may try to drive consensus by shutting down discordant opinions (or even by not inviting people with different ideas to the meeting).
Forcing convergence of ideas and actions too early in the process will make people feel they have not been heard and they will likely disengage from the process. Furthermore, not allowing others to hear different ideas that may shift their own opinions may stifle the creation of generative relationships — important interactions that “produce new sources of value that cannot be seen in advance.”9 It is important to recognize that, as the leader, you may have a clear sense of where you think the group needs to get to at the outset; however, you too need to listen to the divergent opinions and be on the lookout for novel ideas that emerge through engagement. Top
We call this early phase “going slow to go fast,” and it is often when the leader feels the most uncomfortable and may feel that they are losing control of the process. It may also feel as if the group is “spinning its wheels” or wasting time; however, it is critical to allow the group to work through the issues before moving ahead. As a plan starts to coalesce, it is our experience that the improvement work will move much more quickly.
Your role as the leader in this approach is to shift from telling people what to do to facilitating: helping the group determine the best ways forward for the project and helping push the boulders out of the way so they can achieve their goals. This does not mean abdicating responsibility for the change process: you will need to make the boundaries of the work clear, including the fact that the change goal not optional, e.g., the merger is going to happen, the leadership team requires the program to streamline, etc. Top
This work also does not exist in a data vacuum: regular data collection and feedback must occur as with any quality improvement project, so that the group can determine whether it is heading in the right direction. Data feedback can occur in many forms, including less-traditional approaches, such as social media. One group we recently worked with in Ireland relied heavily on WhatsApp to communicate progress.10
In our experience, groups that are not used to being listened to may only weakly engage with a facilitator at first. With repeated engagement that is focused on including everyone, accompanied by evidence that the leader is truly listening, we have found that at least some members of the group will become highly engaged and become change leaders. These early adopters will begin to pull most peers along with them in the change process. As the group begins to take steps toward its goal, they are co-creating the future program with you, rather than buying into your vision. The more they have a stake in its creation, the more the group members will own the changed program down the road. Top
Not an easy path
This approach is not easy. We know from our own early experience using a complexity science-based approach called “front-line ownership”11 that giving ownership of the process to the people you are trying to help change can feel like the opposite of what a health care leader is supposed to do. Furthermore, the feeling of lack of control and the lack of traditional clear timelines and milestones can be unnerving. However, this uncertainty is a necessary part of the iterative nature of the change process. Instead of determining up front what needs to be done, the group learns and course-corrects as the process unfolds.
Finally, modern health care strives to be highly linear and predictable; hence, this approach can significantly clash with other leadership styles and agendas. As the leader, you will need to walk a tightrope between engaging your teams and allowing them to create while meeting the deliverables of your masters. Rarely, if ever, is a leader going to be afforded the luxury of spending as much time as they need on completing a project. However, should the administration drive the change process too quickly and not allow time for engagement, the process may fail to reach its goals. Top
Those of us who have worked in health care administration long enough also have experienced what is perhaps the most difficult challenge. As you work in the direction set by your leadership team, there is a very real chance that your goal is going to change, either because of external (e.g., government mandate) or internal factors (e.g., change at the senior leadership level). If you have been developing a linear process to get the team from A to B, and B suddenly becomes W, you will be ill-equipped (less resilient) to make changes. This is in sharp contrast to the complexity science approach, where your team will tend to be far more resilient and able to adapt to the change while maintaining its core purpose.12
We came to use this complexity approach after years of failure trying to bring about change by following a more traditional, linear model where we were the experts with the ideas who sought buy-in from others. Others have had a similar experience and have, after the fact, realized the importance of engagement when trying to change health care organizations.13 We readily acknowledge that top-down strategies have their place in health care, and we are not advocating that all challenges require this level of engagement. Furthermore, there are many parts of health care that could be improved through standardization and the elimination of waste, where methods such as Lean clearly have a role. That said, the more the people you are trying to change can be consulted, regardless of the process used, the more likely the change will be both successful and sustained. Top
Returning to our hypothetical program merger, we clearly see the challenge as a complex one involving people, behaviours, and relationships, rather than components of a complicated machine or assembly line.
We are reminded of the experience of a participant in a leadership program we are involved with in Ontario, who needed to improve access to cancer treatment in smaller towns roughly 100 km away from where he worked at an academic centre.14 Rather than trying to recreate the academic program in these centres, his initial approach involved listening and engaging the teams at the smaller centres, to understand their unique circumstances. His way forward involved working with the teams to determine the barriers to care and then help them create solutions that would work for them. Two years later, new treatment programs have been created that meet the needs of the local population, with more improvement on the way, all supported by local and regional leadership alignment (Jason R. Pantarotto, Chief, Division of Radiation Oncology, University of Ottawa, personal communication, 11 April 2017). He went slow to go fast. Top
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12.Westley G, Zimmerman B, Patton MQ. Getting to maybe: how the world is changed. Toronto: Vintage Canada; 2007.
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14.Pantarotto J. Enabling equal access to radiotherapy across Champlain LHIN (action learning project). Toronto: Ontario Medical Association, Canadian Medical Association, Schulich Physician Leadership Development Program; 2015.
Michael Gardam, MSc, MD, CM, FRCPC, is chair of the Medical Advisory Committee and on the Board of Directors of the University Health Network. He is on the faculty of medicine, University of Toronto, and the faculty of the Schulich Executive Education Centre, York University, Toronto, Ontario.
Leah Gitterman, MHSc, is with the University Health Network and is on the faculty of the Schulich Executive Education Centre, York University, Toronto, Ontario.
Correspondence to: firstname.lastname@example.org
This article has been reviewed by a panel of physician leaders.