Over the next two or three years, our healthcare system will be forced to undergo a fundamental transformation that will generate a great deal of mistrust and acrimony as 5% to 8% of total spending is removed. So how can your organization prepare for the real truth about the future of our health are delivery system?
Trust will be key in the emerging environment of rapid transformation.
In his book Trustworthy Government, David Carnevale describes trust as “an expression of faith and confidence that a person or an institution will be fair, reliable, ethical, competent, and nonthreatening”. Trust has also been explained as having faith that someone is able to, and wants to control their “dark side” as it would affect oneself or others.
All too often, however, work organizations destroy their employees’ trust. Carnevale writes that many people go to work “with guarded, suspicious, and cynical attitudes. They have lost faith in their organizations. Their hopes and expectations have been mismanaged. The costs of mistrust and cynicism are high. These emotions corrode organizations and destroy high-performance. The loss of trust is a loss of system power in organizations. Trust is an integrative mechanism – the cohesion that makes it possible for organizations to accomplish extraordinary things.
Trust is social capital. It reduces conflict, improves communication, eases cooperation, enhances problem-solving, reduces stress, enables people to realize more satisfactory relationships, amplifies organizational learning, an advances change. Trust is a positive mindset. It needs to be restored in organizations”.
All organizations have behaviours and issues that are “undiscussable”. That is, everyone in the organization is aware of a recurring dynamic or situation that blocks individuals and the organization from achieving desired outcomes and reduces effectiveness. However, no one will openly discuss the situation, or even articulate its existence. The unspoken decision to ignore or pretend to be unaware of the undiscussable is reinforced the longer the tacit agreement of silence is maintained.
Beyond the silos, within the power dynamics among the Health Link CEOs, and among the LHIN leadership, there are issues which everyone very carefully manages to avoid.
People within an organization and within a delivery system begin to engage in what Chris Argyris, in his book Overcoming Organizational Defenses, calls “organizational defensive routines“. These routines are basically avoidance strategies. They are ways of by-passing errors, ignoring difficult issues and problems, and saving face (for yourself or a colleague).
While defensive routines help us to feel secure and in control in the short run, they ultimately erode our sense of well-being and the health of the organization. By masking the dynamics of the situation, defensive routines keep undiscussables underground, and legitimize error and unacceptable behaviour.
From his study of organizational defensive patterns, Argyris warns that the longer the situation continues, the greater the sense of malaise, hopelessness, and cynicism exists. The malaise leads to distancing and blaming behaviours, mediocre performance, and, finally, blow-ups at the individual and organizational levels which destroy the capacity for learning, efficiency and effectiveness.
Surfacing undiscussables and exploring them without blame or defensiveness requires a great deal of courage and skill. Two exercises, “Undiscussables,” and the “Left and Right Hand Column” offer some guidance for teams seeking to unveil and learn from taboo topics.
However surfaced, people find that undiscussables often turn out to be critical factors in solving problems, propelling them toward their vision, or developing their collective ability to learn. Over time, as more open communication develops within the organization, the fear, blame and judgment that feed undiscussables and defensive routines will be replaced with trust and a commitment to generative learning.
“Telling the truth” will only become a common practice in organizations when there is a “safe environment” or culture that supports this norm. People need to consciously create safety for one another by being open to learning, and by their determination to “seek to understand”, rather than to judge. This concept is critical to the well-being of individuals, teams and organizations.
I strive to “tell the truth” in my blogs. Often not “the whole truth” — because it is too often very negative. I try and explore positive issues and point to examples of success — while telling as much of the truth that I know.
A fundamental commitment to the truth is a difficult way to live. It may set you free, but it won’t make you rich. Nevertheless, it is essential for authentic learning, empowerment, partnership and stewardship. By “commitment to the truth”, we do not mean that we are seeking the final word on an issue. There is not one external objective “truth”.
Our understanding of reality is influenced by the assumptions, mental models and experiences that we hold deep inside. A commitment to the truth requires our relentless willingness to reflect on and surface the ways we limit or deceive ourselves from seeing the bigger picture. Continually being open to different understandings of why things are the way they are, demands that we practice honesty with ourselves.
It also demands that we are honest with those around us. Constructive, honest feedback is essential for learning. Communicating anything less than the truth is a common defensive behaviour that is intended to protect ourselves or others. Like all defensive routines, however, deception and avoidance prevents learning and hinders human growth and potential. By committing to the truth, we are collectively able to let go of assumptions and mental models that have held us back, and open ourselves to learning.
This “commitment to learning” and seeking the truth is intimately tied to an organization’s commitment to end secrecy. In his book, Stewardship: Choosing Service Over Self-Interest, author Peter Block states that organizations built on a foundation of empowerment support the idea of full disclosure.
Arguing that knowledge is power, Block supports giving complete information and telling the truth all the time. This position requires “training all employees so as to create business and customer literacy. Full disclosure and full information are the rule, so that people understand the consequences of the decisions that they are making”.
He goes on to write that “full disclosure means to openly discuss bad news and difficult issues. No protecting or positioning allowed. The more sensitive the issue, the more it needs discussing — especially in groups.”
The number of “undiscussables” we have in the health system is really incredible. I openly question why MOHLTC was allowed to avoid the “will of the Legislature” that passed a law that enabled devolution of authority over spending.
An example of an “undiscussables” is that MOHLTC failed to implement this provision of the law, in order to save/protect their own jobs. It has been estimated that 70% to 80% of MOHLTC jobs would vanish with devolution, and that modest growth and skills for allocating resources would be required in the LHINs.
While the MOHLTC does not have veto power formally, nobody is stopping them. There is no devolution. Period.
We express our trust in our institution by the amount of information we allow to become public. The bureaucratic notion of telling people only on a “need-to-know basis” is how patriarchy maintains its grip. Full transparency and disclosure also requires that people do their own communicating. If our goal is to “tell the truth”, we do not need professionals to tell us how to get our message across.”
An “empowered organization” requires individuals who are deeply committed to the truth. Block’s notion of stewardship suggests that we hold in trust the well-being of some larger entity — our organization, our community, the earth itself.
Block says that to hold something of value in trust calls for placing service, ahead of control. It means we no longer expect leaders to be in charge, or out in front. We search, so often in vain, to find leaders that we can have faith in. Our doubts are not about our leaders’ talents, but about their trustworthiness. We are unsure whether they are serving their institutions or themselves”. By modeling the values of stewardship, service and trustworthiness, leaders can steer their organization toward vibrancy and health and commitment to achieving the shared organizational vision.
A “commitment to the truth” is also essential to establishing real partnerships within and amongst organizations. Block describes how traditional hierarchical structures based on uneven power relationships between bosses and subordinates make it difficult and unsafe to tell the truth. Bosses must pretend to know all the answers, since that is what is expected of someone in their position.
In turn, employees must strive to hide mistakes and areas that could be improved — so as to avoid being blamed by their “superiors”. By redistributing power within organizations to create true partnerships, we are able to create an environment in which people feel less vulnerable, and are therefore more honest with each other.
It can get even more complicated in structures like Health Links — which is a structure that requires CEOs who normally pull apart, to begin to pull together. To avoid one another, and to avoid the truth about the need for true collaborative action, many Health Link CEOs have simply turned over the responsibility for this little “pilot project” to middle management. They don’t intend to use Health Links as a platform to transform their system.
The fact is that the effort behind many Health Links is mostly about the 5%, rather than how the CEOs will transform the design of systems, structures and processes — based on what they are learning from the 5% of high users.
So, the truth is, many Health Links are compliant, but few are heading for transformation, but that itself becomes an “undiscussable”.
No matter whether our concern is with learning, empowerment, stewardship or partnership, a “commitment to the truth” begins with deep personal commitments from the people at the top — senior management and the board. Block believes that what is true, is known to each of us — that we all have the knowledge and answers within us.
He writes, “the spirit demands an inward focus,” needing reflection, dialogue and clarity about our own intentions. Looking externally at the commitment of others diverts us from taking responsibility for our own choices and actions.
To affirm the spirit, we need to ask ourselves what has meaning for us, what we most desire and believe in. Spirituality, or “the process of living out a set of deeply held personal values and honoring forces — or a presence greater than ourselves — requires that we be committed to the personal truth that lies in each of our hearts.”
In his book, Trustworthy Government, David Carnevale explains the importance of participative processes for building high-trust, cooperative and high performance organizations.
He writes, “participation elevates feelings of personal efficacy by granting staff more control over their work lives. Involving employees means trusting them with information, power, authority and responsibility. They interpret their enhanced control over the conception and execution of their work as expressions of confidence, and they respond accordingly. Trust is a reciprocal attitude”.
Carnevale concludes, “the message is clear. Trust and high performance are impossible if the organization deals with employees just in terms of their work roles, puts up defenses that impair free expression, uses manipulative methods to motivate workers to do what it wants, and attempts to control everything and everyone. Staff who are suspicious and cynical become absorbed in self-protective practices. They are less likely to take risks, to speak out when it is called for, to question ideas that need examination, to participate during meetings, or take a chance that a fresh approach might be the answer to a problem. They fear speaking truth to power. ”
“Who, after all, is going to expose themselves to risk or commit to an organization that weakens their sense of efficacy, or threatens their very existence? Who identifies with a system that keeps them small?”
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