Leading Change in Health Organizations: A Detailed Guide

Enduring Organizational Values and Beliefs

• Every health organization is built upon a foundation of values and beliefs that shape its culture.
• These values and beliefs guide health leaders in making strategic decisions, balancing efficiency with what is best for patients and communities.
• Values are generally stable over time. Beliefs should emphasize excellent patient care, efficient operations, and teamwork.
• Health leaders influence values and beliefs to encourage desired attitudes and behaviors.

Values, Beliefs, Attitudes, and Behaviors

• Transformational leaders can effectively solidify or change values, beliefs, attitudes, and behaviors.
• Charismatic leaders understand the needs and values of followers and can motivate commitment to change.
• Values and beliefs are reflected in strategic plans and organizational statements.
• Attitudes are perceptions and opinions of the staff.
• Behaviors are observed actions.
• Health leaders should communicate expectations regarding values, beliefs, attitudes, and behaviors.
• Understanding team members helps align their values with the organization's mission and vision.
• Transactional leadership focuses on behaviors, using social exchange to motivate subordinates.
• Transformational leadership focuses on attitudes, connecting individuals to the organization's mission and vision.
• Transformational leadership can shape the organization's culture over time and influence subordinate values.
• Change involves adjusting behaviors and attitudes, and sometimes modifying beliefs and values.
• It's important for health leaders to consider the interconnectedness of values, beliefs, attitudes, and behaviors with organizational culture because these elements can either reinforce or conflict with each other.
• Consistent focus can enable health leaders to modify these elements as part of organizational culture development, using Edgar Schein's mechanisms and transformational leadership principles.

Leadership and Change

• Transformational leaders are well-positioned to create positive change.
• Competent communication is crucial for transformational leaders.
• Transformational leadership is most effective when elements synergize to change the culture and improve the organization.
• Transformational leadership builds commitment to the organization's mission, vision, strategies, and goals, as well as empowering followers to achieve them.
• Burns (1978) stated transformational leadership involves leaders and followers raising each other to higher levels of morality and motivation.
• Expectation and goal setting, empowerment, and effective communication focus the team, enabling significant system improvements.
• Transformational leadership differs from charismatic leadership. Charisma is necessary but not sufficient for transformation.
• While charismatic leaders seek personal loyalty and may keep followers dependent, transformational leaders empower and elevate followers (Bernard Bass).
• Schein's primary embedding mechanisms and secondary reinforcement mechanisms are important for developing and maintaining culture within the context of change.
• Consistent and moral application enables quicker change, greater benefits, and enhanced leader status.

Strategies in Creating a Culture of Change

• Health leaders can use transformational leadership strategies, primary embedding and secondary reinforcement mechanisms, and the dynamic culture leadership (DCL) model processes to develop and synthesize a model for creating a culture of change.
• Bernard Bass expanded on Burns' work to develop the theory of transformational leadership, which measures the leader's influence on followers.
• Health transformational leaders create trust, admiration, loyalty, and respect through their actions, motivating followers to exceed expectations by increasing awareness of task outcomes, encouraging transcendence of self-interest for the team, and activating higher-order needs.

Transformational Behaviors and Actions

• Charisma: Influencing followers by arousing strong emotions and identification.
• Intellectual stimulation: Increasing follower awareness of problems and offering new perspectives.
• Individualized consideration: Providing support, encouragement, and developmental experiences.
• Inspirational motivation: Communicating an appealing vision and modeling appropriate behavior (Bandura's social learning theory).

Primary Embedding Mechanisms

• What leaders pay attention to, measure, and control.
• Leader reactions to critical incidents and organizational crises.
• Deliberate role modeling, teaching, and coaching.
• Criteria for allocation of rewards and status.
• Criteria for recruitment, selection, promotion, retirement, and excommunication.

Primary Embedding Mechanisms (continued)

• Schein emphasized that leaders communicate assumptions both explicitly and implicitly.
• Inconsistencies become part of the culture.
• Consistency is key: Health leaders must predetermine direction and stay on task.

Secondary Reinforcement Mechanisms

• Support the primary mechanisms.
• Include:
  • The organization's design and structure
  • Organizational systems and procedures
  • Design of physical space, facades, and buildings
  • Stories, legends, myths, and parables
  • Formal statements of philosophy, creeds, and charters
• These are "secondary" because they only work if consistent with the primary mechanisms.
• Secondary mechanisms are less powerful and harder to control but can strongly reinforce primary messages if managed well.
• All mechanisms communicate culture content to staff. Consistency and conscious utilization are essential.

DCL Model Process

• Involves assessing and aligning leadership and management teams to ensure broad knowledge, skills, and perspectives.
• The leader's use of sequential and building elements supports the development of the desired organizational culture.

Process Constructs

• Communication improvement: Predetermined modeling, training, rewarding, and assimilation of effective communication.
  • A confirming and supportive environment with media-rich channels and conflict management competency is most effective.
• Strategic planning: Structured, inclusive process for determining mission, vision, strategies, goals, objectives, and action steps, aligned with values and external expectations; Continuous, "living" planning is essential.
• Decision-making alignment: Aligning decisions with strategic and operational plans, delegating appropriately, and using policies/SOPs for consistency.
• Employee enhancement: Assessing and adjusting employee responsibilities based on knowledge, skills, abilities, experience, and trustworthiness.
• Knowledge management and organizational learning: Capturing and using organizational knowledge for improvements.
• Evaluating, reflecting, and retooling: Honest assessment of the DCL model cycle for continuous improvement.
• Consistent use improves processes and develops a leadership-vision-reflecting culture, enabling effective maneuvering in dynamic situations.

Predetermined Actions and Organizational Culture to Develop

• Integrating leadership aspects can realize positive change.
• By scanning and assessing the environment and organization, leaders develop a predetermined direction, vision, and optimal organizational culture aligned with the current mission.
• This should be documented and planned over time.
• Planned actions should aim to achieve the envisioned future.
• Health leaders must plan, practice, and ensure consistency to achieve desired outcomes.

To Turn the Desired Future into Reality:

• Change is likely required
• Active situational leadership (mix of transformational and transactional),
• Frequent quality communication
• Inclusive planning, decision-making
• Empowerment along with an appealing vision are needed for success.

Leadership-Facilitated Organizational Change Model

A model for leader-facilitated positive health organizational change:

Vision

• Predetermined vision and culture changes selected by the leadership team.

Transformational Leadership Characteristics:

• Charisma
• Intellectual Stimulation
• Individualized Consideration
• Inspirational Motivation
• Performance Orientation
• Decisiveness
• Team Integration and Collaboration
• Diplomacy
• Benevolence
• Administrative Competence
• Transactional Leadership (reward for performance) where appropriate

Leadership Team Actions and Behaviors

• Primary embedding mechanisms:
  • What leaders pay attention to, measure, and control
  • Leader reactions to critical incidents and organizational crises
  • Deliberate role modeling, teaching, and coaching by leaders
  • Criteria for allocation of rewards and status
  • Criteria for recruitment, selection, promotion, retirement, and excommunication
• Secondary reinforcement and articulation mechanisms:
  • Design and creation of the organization's design and structure
  • Design and creation of the organizational systems and procedures
  • Design of physical space, facades, and buildings
  • Creating and telling of stories, legends, myths, and parables about important events and people
  • Developing and publishing formal statements of organizational philosophy, creeds, and charters

Organizational Actions and Behaviors by Leaders and Subordinates

• Dynamic culture leadership process: vision and organizational alignment.
• Communication improvement
• Strategic and operational planning
• Decision-making alignment
• Employee enhancement
• Knowledge management and organizational learning
• Evaluation, reflecting and retooling, and repeating the process

Organizational Outcomes

• Predetermined leadership incrementally transformed and realized

Managing Conflict & Transition

• Transformational leadership shapes, expresses, and mediates conflict.
• Change leads to conflict, requiring management for positive results.
• Consistent delivery of the change message and organizational vision reinforces it while easing tension.
• Each transition step should be planned with subordinate involvement.
• Including stakeholders helps smooth transitions.
• Expect turbulence; use supportive communication and media-rich channels.
• Succession planning ensures smoother leadership transitions.

Maintaining a Culture of Adaptive Change

• Nourishing and maintaining a culture of change is important.
• Organizational culture is a learned pattern shared across generations.
• Only adaptive cultures maintain superior performance over time.
• Health leaders should develop a transformational culture promoting continuous improvement and adaptability.

Transactional Culture Attributes:

• Concentration on contractual relationships.
• Job assignments including rules and benefits.
• Jargon implying rewards for actions.
• Performance-contingent rewards.
• Management by exception.
• Individual work.
• Lack of identification with the organization.
• Leaders as negotiators and resource allocators.
• Discouragement of innovation and risk.

Transformational Culture Attributes:

• Sense of purpose and family.
• Long-term commitments.
• Shared interests and interdependence.
• Leaders as role models, mentors, and coaches.
• Socialization of new members.
• Adaptive norms.
• Emphasis on vision, not threats.
• Norms change with the organization's environment.

Developing a Leadership Model

• Incorporate diversity, power, and organizational transformation competencies.

Suggestions:

• Model expected behavior.
• Communicate expectations and provide training.
• Revise structures and reporting relationships.
• Conduct team-based planning.
• Use primary embedding and secondary reinforcement mechanisms.
• Utilize the DCL model sequential processes.
• Communicate consistently.
• Continuously assess the internal and external environments.

Knowledge Management and a Learning Organization

• Learning organizations are open, robust systems.
• Knowledge management is a change strategy involving creation, accumulation, and sharing of knowledge.
• Effective knowledge management impacts institutional knowledge and organizational learning.
• It empowers the organization to achieve its vision and compete effectively.
• Consistent knowledge management over time creates a learning culture.

Distinctions Between Data, Information, and Knowledge

• Data: Objective facts.
• Information: Facts used to convey a relevant message.
• Knowledge: Actionable information that conveys understanding for problem-solving.
• Knowledge is a dynamic mix of experiences, values, and insights that frames new information.

Three Processes of Importance

• Knowledge accumulation
• Knowledge creation
• Knowledge sharing

Example:

• Data: $270$ people positive for coronavirus, $30$ deaths, $200$ hospitalized.
• Information: Healthcare organizations are preparing for potential transmission due to travel.
• Knowledge: COVID-19 is easily transmissible. CDC has developed PPE and social distancing guidelines.

Accumulating Knowledge

• Health organizations must have data, information, and knowledge to draw from.
• Identify essential data and information.
• Clarify the organization's mission, vision, and core values.
• Discover existing knowledge and put it into context.
• Gather and organize knowledge to make it useful.
• Focus on the future if the intent is to inform and influence decision-making, allowing discussion and debate to accumulate existing knowledge

Creating Knowledge

• Knowledge generation and usage is a work in progress.
• Continually acquire and create new knowledge.
• Experiments are crucial because they provide data and information.
• Employees learn by taking chances and by making mistakes.
• View mistakes as opportunities to learn and improve patient care and business processes; they should be acceptable in the organization.
• Understand culpability: Would someone with similar experience make the same mistake?
• Focus on system failures rather than blaming individuals.
• Patient care should be error-free.
• Evaluate errors through root cause analysis (RCA).
• Share knowledge gained from RCA across the organization.

Tacit vs Explicit Knowledge (Nonaka)

• Explicit knowledge is transferable by language.
• Tacit knowledge is hard to convey, resulting from subjective experience.
• Tacit knowledge enables the capture, assimilation, creation, and dissemination of explicit knowledge.

Sharing Knowledge

• Capturing and storing knowledge are the cornerstones of knowledge management.
• The most popular approach combines a database form with a technology-related platform.
• Once knowledge is stored properly, it can be disseminated throughout the organization.
• Knowledge databases should be broad in scope for greater usability.
• Leaders must be obsessive about noting and correcting errors in their stock of knowledge.
• The target audience of the knowledge database must be clear.
• Organizations today can deliver knowledge via technology platforms.

Summary of Knowledge Management and Organizational Learning: A Five-Step Approach

1. Identify what is critical to the organization.
2. Discover existing knowledge and put it into an organizational context.
3. Acquire or create new knowledge.
4. Establish knowledge databases.
5. Distribute knowledge to the appropriate audience.
   Building a culture of learning within the health organization to foster the development and sharing of knowledge is an essential element in establishing and maintaining an effective, efficient, and efficacious knowledge management system.

What Kind of Leader Do You Want to Be?

• What leader do you want to become?
• Develop leadership knowledge, skills, abilities, and competencies.
• Leadership: Dynamic creation and maintenance of organizational culture and strategic systems that focus collective energy, leading people and managing resources, toward meeting external needs efficiently and morally.
• Internalize leadership as a continuous process to improve constantly and stay credible.
• The desire to be great comes from within.
• Fairholm summarizes "inner leadership" principles based on empowerment, engaging the inner leader.
• Inner leadership leads to the leader being capable of assuming the following responsibilities:
  • Goal setting
  • Delegating followers
  • Encouraging participation
  • Encouraging self-reliance
  • Challenging followers Focusing on workers
  • Defining followers' roles

Linking Inner Leadership to Theories and Models

• Understand your style and tendencies to emphasize strengths and address weaknesses. Practice integrating personal style into leadership.
• Create and communicate a clear leadership vision to subordinates and potential employers.
• Leadership development is a top concern, developed through effort over time.

It's Okay to say, "I Don't Know"

• Health leaders face unique challenges due to organizational complexity and a lack of wide understanding.
• The public does not understand the specializations among administrators, physicians, nurses, and other allied health personnel and employees.
• Leaders must manage accounting, marketing, logistics, human resources, plus FDA regulations, licensing, technology, and best practices, while maintaining near-perfection in patient care.
• Health leaders may lack experience in daily activities, relying on subordinates' competence.
• Unlike fast-food managers with firsthand experience, health leaders must trust their team's reporting.
• A health leader will never be as competent as individuals across specialties in their specific tasks.
• Health leaders must be comfortable not knowing everything, developing systems for an efficient healthcare environment.
• Trying to know and control everything leads to frustration and failure.
• Develop a presence throughout the organization and understand different areas.
• Building a trusting relationship with peers is critical.

Maintaining Relevancy and Credibility

• Address relevancy and credibility by constant self-assessment.
  These critical self-assessment issues must be constantly addressed and evaluated by the leader, at least on an annual basis. Additionally, both relevancy and credibility are mutually exclusive issues the leader must pursue through individual strategies. 74,75
• Credibility is measured through experience, outcomes, and trust.

Experience

• A leader with little previous experience in the day-to-day operations of the health organization may not be perceived as credible. However, the defining of experience becomes even more complex when discussing the specific nature of the experience of the individual.
• Nurses may not be perceived as having credible experience in leading health organizations if their 20-year familiarity with leading people in health organizations has been restricted to leading only other nurses.
• Professional administrative leaders without clinical degrees may look at a physician leader with skepticism if the physician has risen to a position of authority based on his or her medical and clinical prowess rather than by taking on administrative and management developmental activities.
• Physicians might view administrators with only a master's degree without enough patient care experience to manage them.
• The dyad leadership model pairs a nonclinical administrator with a physician leader for balanced synergy.
• Credibility is highly connected to trust
• Leaders should maintain positive relationships, as trust is essential.

Outcomes

• They are related to outcomes with human resources:
  • Organizational satisfaction
  • Leader and employee development opportunities
  • Formation and maintenance of positive relationships with stakeholders
• Employee treatment (acknowledging input, respecting candor, protecting autonomy) is crucial.
• Loss of trust can be detrimental.

Relevancy

• Relevancy: Ability to consistently contribute to the organization's success.
• Indicators of relevancy: Growing market share, increasing prominence, improving quality.
• High outcomes with low employee satisfaction indicate weak effectiveness.
• Credibility and relevancy are linked, achieved through: joining professional organizations, service, continuing education, and professional development.

Professional Organizations

• Membership in professional organizations is critical to establish a leader's credibility and relevancy.
• Decision to be tied to a leader's current work environment.
• The greatest benefit offered by any professional organization is the opportunity to network and collaborate with peers from similar organizations.
• Despite the competitive nature of the business of health care, professional organizations seek to share best practices between and within similar organizations along the continuum of care.
• Professional organizations are multidirectional warehouses where topical information from the environment is captured and then disseminated to leaders and organizational entities.
• Failing to join, contribute to, and maintain a presence in a professional organization of choice will surely decrease opportunities for both organizational and personal growth.

Service

• Health professionals should consider service from a volunteer perspective that involves contributing to their own organizational entity, their community, and their personal professional organization of choice.
• Leading by example and volunteering are critical parts of any leader's success.
• OCB initiatives of their employees-that is, doing extra work for the organization that benefits the organization, albeit without compensation-the leader must model this behavior him- or herself and lead by example.

Community Service

• Volunteering on community boards or participating in charitable outreach provides positive marketing.
• Service to professional organizations can lead to increased opportunities if elected to a national position.
• Service to the organization, community, and profession increases opportunities for personal and organizational growth.

Continuing Education

• The speaker was very well known to the group and had achieved a level of national prominence and the respect of his peers.
• Continuing education (CE) is different for practicing patient providers and administrators.
• The elements of CE are generally described as twofold:
  • Continuing health education (CHE), or nonclinical education
  • Continuing medical or nursing education (CME/CEU), or clinical education.
• For clinical professionals, the need for CME is immediately evident.
• For nonclinical professionals, the need for CHE may be less mandated by state and national licensing agencies.
• CE opportunities are generally widely available to a leader in the modern era.

Mentoring and Professional Development

• It is incumbent upon the leader to become a mentor to the next generation of health leaders.
• Assertively seek out mentors, ask questions, and follow the example of those leaders you find successful.
• Seek a mentor from another organization, this is not a rare situation.
• Leaders all along the health continuum should seek opportunities to attend seminars and presentations on a continual basis.
• A leader should allow for at least 30 to 60 minutes of professional reading each day to maintain a sense of relevancy with events in his or her environment.
• Finish a quality leadership/management book monthly and apply skills learned.

Development of Systems to Lead People and Manage Resources

• To accomplish essential tasks, leaders must develop, refine, evaluate, and implement systems.
• Put the dynamic culture leadership (DCL) model into practice as a basis of a system to lead people and manage resources.
• Style, behaviors, and actions must be consistent with organizational culture, values, strategies, and goals.
• Assess if the current systems and processes are aligned. How do you keep them aligned and consistent?.
• Use the DCL model to improve and integrate systems consistently.

Take Care of People

• The most important resources in any organization are the human resources.
• Without skilled, dedicated, and competent individuals to do the work of the organization in an ongoing manner, the organization is sure to fail.
• Employees will reflect the organization's values and communicate them to customers.
• Taking care of people is based not only on monetary and work environment factors but also on moral grounds.
• Diversity helps achieve higher quality and efficiency by broadening the resource pool and increasing differentiation.
• Leaders must provide clarity, autonomy, respect, and belonging (CARB):
  • Clarity through job descriptions and meetings.
  • Autonomy by trusting employees' skills.
  • Respect for time, opinions, and needs.
  • Belonging to enhance productivity.

Take Care of Resources

• Resources are the materials and technologies that the leader needs to perform the business of the organization.
• Provide appropriate resources to employees.
• Stay abreast of emerging technologies.
• As fiduciary agent, manage and take care of resources to better lead people.
• Maintain a list of all resources with their location, users, maintenance schedule, and calibration record.
• Routinely inventory all resources and check maintenance.
• Track committed and obligated intangible funds.
• New leaders should meet monthly with the financial officer for the first 6 months, then quarterly.

Pay Attention to Details

• Explicitly communicate vision, mission, values, and goals.
• Attend to details without micromanaging.
• If not detail-oriented, develop the skill through consistency.

Attend to the Communities Served by the Organization

• Be knowledgeable and involved in the community.
• Conduct community assessments for health improvement and preparedness.
• Leaders establish and maintain trust with organizations, populations of providers, and outside stakeholders by becoming involved with and integrated into the community rather than isolating their personal and professional practices.
• Effective leaders see community involvement as a natural part of outreach.

Share Your Knowledge

• Health leaders freely share best practices.
• Contribute to the profession's knowledge by authoring or supporting descriptions of best practices.
• Publishing and speaking increases credibility and recognition.

Partner with Community Leaders

• Joint ventures are becoming more common in the healthcare field as organizational entities try to achieve economies of scope and scale.
• Leaders must partner with those effective in technology, claims payment, health analytics, or billing.
• Maintain networks for support in lean environments.
• Today's savvy health leader is aware that the leader of a perceived rival organization today may be the organization's rescuer tomorrow in resource-restricted environments if positive relationships have been maintained.

Integrity

• Consistency in practice and genuine care leads to integrity.
  Lack of integrity is impossible to disguise for long periods.
• Achieve this by leading by example and taking responsibility.

Relationship Building and Communication

• Relationship and communication are important for health leaders.
• Apply this to all stakeholders.

Factors to Strengthen Relationships

• Relationships reflect feelings, roles, norms, status, and trust.
• Every message has content and relationship dimensions.
• Communication should provide content and positive relationship information.

Nonverbal Communication

• More prevalent than verbal (65% of meaning).
• Includes eye contact, facial expressions, body posture, and movement.
• Primarily communicates emotions (93%).

Additional Factors

• Frequent communication that is timely, useful, accurate, and in reasonable quantity must be considered to reinforce and validate the relationship.

• Disclosure relates to the type of information you and the other person in the relationship share with each other; disclosure is one factor that can help you "measure" or evaluate the depth and breadth of a relationship. The "deeper" the information disclosed, the closer the bond of the relationship.

• Self-disclosure should be:

  • Ongoing
  • Reciprocal
  • Timed
  • Relevant
  • Incremental

• Trust: Built through honesty, inclusion, and sincerity.

• Cultural competence: Understanding and adapting to different cultures.

Have Fun

• Managing long-term issues can lead to burnout.
• Enduring leaders see it as an art and extension of personality.

Summary

• This chapter discussed the globalization of leadership
• The need to leverage technology, adopt followership, and understand influence and power.
• Knowledge management and organizational learning adapt the organization to its environment.
• Use integrative models to foster change.
• What kind of leader will you be? What will your organization accomplish because of you?