While our provincial government has been saying they are in the midst of “transforming” our health system, it is important to know that 70% of all large-scale transformations fail — so learning how the 30% succeeded is very important!
The Balanced Scorecard Collaborative says that the most common reason for failures in Balanced Scorecard transformation case histories is a “lack of commitment/alignment at the top” – that is, among the executive leadership of the organization. The challenge is, while our senior healthcare managers are well-paid, they are often very cynical about the so-called “health reform agenda” that has pre-occupied Queen’s Park and the LHINs for a decade.
In the healthcare sector, this increasing cynicism requires operational leaders to shift from reactive crisis management, to proactive strategy development and strategy implementation. It requires governance and managerial leadership to be “in service” to those who actually deliver healthcare services to the citizens/owners and taxpayer/patients.
At the operational level, how can a CEO create such a fundamental shift in the thinking and behavior of their top management? Professional leadership coaches and change management scholars would emphatically say that it must start with a commitment by the CEO to model change and learning themselves.
The strategic decision to become a “Learning Organization” means that CEOs need to learn how they can lead and manage such an organization. They need to learn more about how they can be developmental coaches and facilitators. They need to determine how they will personally model learning, growth and change.
That means “learning-how-to-learn.” It means understanding adult learning methodologies/learning styles, and developing their own capacity to be developmental facilitators and coaches to their senior team members and to their middle managers.
While external coaches and facilitators can “add value” to such a process, it is essential that the Balance Scorecard process be led by the CEO. Others can help, but unless the CEO leads it, the gains will only be incremental, the pace will be very slow, and the changes are not likely to be sustainable.
In the meantime, there can be hundreds, sometimes thousands of employees, awaiting strategic direction and leadership from the top. How will that direction come?
By investing at least two-days-per-month in strategy dialogues, a traditional Senior Management Team which is focused primarily on operations, can be transformed into a High-Performance Strategy Team that has the capacity to actually lead and manage the organization’s transformation journey. The challenge for senior managers is: how they will change their relationships with their direct reports? How do they liberate and guide people to achieve the results required?
Organizations that produce superior results with Balanced Scorecards are often those where the middle managers have transformed themselves from command and control in organizational silos, to a new emphasis on developmental facilitation for integrated, cross-functional high performance teams. This new skill for developmental facilitation is different from basic facilitation. In developmental facilitation we teach skills and empower the team to generate solutions.
Experience tells us that middle managers will not transform until and unless their bosses have authentically transformed – and are themselves modeling the thinking and behavior that middle managers are expected to exhibit for front-line workers.
This is a major challenge for CEOs: how to develop the capacity of their senior and middle managers to be highly strategic and capable of leading and managing others through a transformative learning experience in which the entire system is designed to be patient-centred.
From the CEO’s perspective, since their own success is dependent upon the success of each of their direct reports, they clearly have a major stake in seeing that each of their senior managers will be successful at achieving the outcomes for which they are accountable. After all, when the CEO’s direct reports are successful at achieving their outcomes, the CEO is successful. And, when the CEO is successful at achieving a balance of outcomes – everybody wins.
In a best practice Accountability Agreement process, each executive selects outcomes, themes and measures in the BSC that they helped develop – and then list what they will be accountable for achieving. They also list the supports that they require to be successful; and, what they believe should be the consequences of success and failure on themselves.
The key to this best practice design is achieving the right balance of empowerment and accountability. “The most common reason for BSC failure is lack of commitment/ alignment at the top – among the executive leadership of the organization.”
Barry Oshry, author of Seeing Systems: Unlocking the Mysteries of Organizational Life explores the organizational dynamics of complex, adaptive systems and the conditions of three “spaces” in organizations: the top space, the middle space and the bottom space.
A key leveraged action for successful balanced scorecarding requires the integration of middle managers into cross-functional teams. Their role needs to shift from day-to-day operations within a silo, to being developmental facilitators and coaches of cross-functional high-performance teams.
The condition of the middle space is “diffusion” according to Oshry. He calls them the “torn middles” – because they are constantly being pulled in numerous directions by the many needs of their subordinates in the bottom space, and by the demands of their bosses in the top space.
Middle managers, trapped in their silos, often feel isolated from one another. Hospital Culture Survey Results also tell us that they feel alienated, lonely and fearful of being blamed. To survive in such toxic work environments, middle managers and senior managers often engage in what Chris Argyris calls “defensive routines”.
In Overcoming Organizational Defenses, Argyris explores defensive behaviors and organizational patterns. He explains that these routines are designed to “cover up” or by-pass inefficiencies and ineffectiveness in our organizations. He identifies defensive routines as “errors of design” which he says are at the heart of organizational effectiveness. He says that if organizations and their people are to thrive, defensive routines must be surfaced and reduced.
Many CEO’s understand what it is like to live in a “threatening” environment, rather than a “innovation” environment. Threats come from above: from Queen’s Park, from the LHIN, from their Board. In such environments, people learn how to “fake compliance” and “avoid truth”.
In such environments, “politics” and “gaming” begin to dominate the “inner-circles” of power, creating “winners” and “losers” — none of which has any impact on the core business of the organization, and yet, preoccupies the energy and attention of leaders at all levels.
The CEO also needs to bring together their senior team with middle managers to engage in strategy development, organizational alignment and strategy implementation dialogues on an on-going basis. In organizations that achieve accelerated change, the CEO and Strategy Team often spend at least one-day-per-month with middle managers on strategy dialogues — in addition to their own 2-days-per-month as a Strategy Team.
Best practices suggest that these dialogues should be designed as “learning-by-doing” workshops — on a “just-in-time” basis — at which the CEO and the Strategy Team members tap into the collective intelligence of the middle managers — as they determine the organization’s evolving strategy, and select the indicators that will measure their progress.
Perhaps the CEO’s greatest vulnerability today is the growing alienation of front-line healthcare providers. While the CEO must survive in an increasingly threatening external environment, internally, direct service providers are less and less prepared to experience “yet another management fad” that past experience tells them will fail.
The best CEOs are those whose primary strategic goal is to provide the type of support that front-line care providers need to ensure high-quality, safe services which patients and their families rank highly. But there might not be a lot of those.
I was surprised at the results of the Health Leaders’ Survey @ TedBall.com that ranked “patient-centred care” and “improving the patient experience” as 13th out of 17 priorities. In contrast, I am certain these would be the number one priority of front-line care providers.
That is why CEOs need to lead a bottom-up transformation in which middle managers provide support and coaching to front-line care providers who can redesign the core and support systems structures and processes to be patient-centred and family-focused.
In the post-SARS/Ebola-era, our healthcare providers also face a wide-range of deeply complex emotions related to their own personal and family safety. If they are to succeed, CEOs and their management teams must understand that their organization is profoundly human. They need to understand their organizations not as a series of fragmented organizational component parts that make up the whole, but as a network of human relationships. In the healthcare system today, many of these relationships require healing to take place.
Organizational scientist, Barry Oshry, describes the condition of the front-line worker as “vulnerable”. From the healthcare provider’s perspective, various forces in the organization and in government provide constant threats to their security and quality-of-life. Oshry says that the “blind reflex” to this condition is to coalesce or combine together.
Oshry says that people in the bottom space often feel “oppressed, ignored, unrecognized and mistreated”. They experience negative conditions and they hold management and governance primarily accountable for many of the problems that they experience. They experience “blaming down” by management and governance, and participate in “blaming up”.
People in the so-called “bottom space” draw together to form a more powerful “we”. However, all too often people in the bottom space do not hold themselves personally accountable for how their own behavior and attitudes may be contributing to the deterioration of their quality-of-work life.
In a transformed organization, front-line service providers take responsibility for their condition and the condition of the organization. They pull together as a positive force for change and improvement. They are empowered to control and coordinate their own work; and, they participate in the development and implementation of the organization’s strategy through the BSC cascading process.
The truth is that the answers to healthcare’s most complex problems can be found in the hearts and minds of the people who deliver services to patients and their families.
Liberating the “bottoms” and integrating the “middles” is how Learning Organizations successfully transform to achieve their outcomes.
Below is a chart that outlines the conditions, reactions and solutions to the challenges faced by people in the Top, Middle and Bottom Spaces in your organization.