The future is changing rapidly
While the world of work is changing exponentially (driven by an explosion in new technology and evolving social expectations), our responses to this change are often slow - and healthcare is no exception.
Like many other industries, health is challenged by systems, mindsets and approaches that reflect a bygone era of modest or incremental change - one where linear, predictable processes and management systems were enough. All over the world, these are failing organisations as they grapple with an increasingly complex, fluid, technology-enabled reality.
Many health organisations lack the culture and tools they need to structure themselves, engage employees, share information, make decisions and track performance. The impact of these constraints is severe and limits an organisation’s ability to adapt and grow.
In order to manage this change, and the reality of our new working environments, we need new tools and skills, based on a more sophisticated understanding of the human condition. As well as helping humanise and improve current care delivery, these tools and skills would help us tackle problems (be they targeted and within a specific domain, or part of significant population-based challenges) in a new way, by forming flexible, temporary teams to operate and find solutions in ambiguous environments.
For leaders, the ability to ‘form, un-form and re-form’ teams is a new skill that will be particularly important as we move towards more ‘networked care’ that transcends traditional team, departmental and organisational boundaries, and focuses less on isolated interventions across the care continuum. These tools will also be the key to getting the best out of large groups of people.
Incremental vs. exponential thinking when growing a business:
Incremental thinking delivers immediate and steady results, while exponential thinking generates results that accelerate over time. Given that the wrong expectations can lead teams to quit the exponential path too soon, it’s important leaders help people understand that the path we’re on may take longer - but the results will be greater over time.
The role of humans
As the world becomes increasingly automated and AI-driven, what is the role of humans? Even for those who can see the clear benefits and value this will bring to care, it’s an important question to ask.
Ironically, for decades society has been on a mission to make machines more like humans - and started treating humans more like machines.
We’ve been trying to give machines personalities to give them more tailored and personal, while simultaneously trying to remove all variation from humans so they follow rules and do routine tasks.
The emerging role for humans is to be more human, so we can do things that machines can’t - those that involve creativity, vision, empathy and engagement. We’ll also need our very human skills to ensure we don’t abdicate important parts of decision-making to technology (either by overlooking the value of real-time human observation/interaction or undermining hard-won instinct).
Complexity in healthcare
It’s no surprise to anyone working in health that it’s complex and unpredictable - and becoming increasingly so. Despite this, the healthcare industry’s interest in complexity as a discipline and science has been largely superficial (both theoretically and empirically).
As Trisha Greenhalgh and Chrysanthi Papoutsi aptly noted (both Oxford University-based, from their respective viewpoints as primary care physician and researcher), “[it] is fashionable to talk of complex interventions, complex systems, complex patients, wicked problems, and the like. However, with few exceptions, we embrace the theme of complexity in name only and fail to engage with its underlying logic¹."
¹Greenhalgh & Papoutsi 2018, Studying complexity in health services research: desperately seeking an overdue paradigm shift, BMC Medicine, 16(95), doi: 10.1186/s12916-018-1089-4
Implications for organisations
In order to grapple with the increasing pressures they face, health organisations - like many others - are experimenting with new approaches and organisational structures that increase the speed of decision-making, decentralise power and supercharge agility. However, new structures only work when the culture exists to support them. Otherwise, the intent of the structure gets lost as the people revert to old patterns - a challenge being seen in some multi-disciplinary teams, for example, where legacy mindsets around the respective roles of medical, nursing and allied health undermine the patient-centred intent. Ultimately, we collectively need to move into new ways of working which are less oriented towards ‘command and control’ and more reflective of complex networks.
What this means for you as a leader
Complex operating environments produce more complex challenges. Understanding the difference between a complicated problem and a complex one is important for today’s leaders - because the strategies and tools you need for each are largely not interchangeable. Sometimes a problem can morph from one state to the other (either from complicated to complex, or vice versa), so you’ll need to be ready to spot the shift and adapt your approach accordingly.
So what are the differences? A recent Harvard Business Review article by Gokce Sargut and Rita Gunther McGrath offers these distinctions:
“... the main difference between complicated and complex systems is that with the former, one can usually predict outcomes by knowing the starting conditions. In a complex system, the same starting conditions can produce different outcomes, depending on interactions of the elements in the system.”
For example, building a highway is complicated, but managing urban traffic congestion is complex. Likewise, building a state-of-the-art air traffic control centre is a complicated challenge in executing a project, while directing air traffic is complex, involving in-the-moment problem-solving. (John M Kamesky)
The implications for leaders are clear. In particular, leaders must shift from a technical leadership style where problems are clear and can be solved repeatedly with expert knowledge to an adaptive leadership style, where change originates from the collective intelligence and requires constant sensing and learning. This is particularly important for adaptive change, where organisations encounter or design intentionally destabilising events that have the potential to move the whole system to a higher level of performance.
For leaders moving into this space of adaptive leadership, there are six key principles to follow:
2. Identify the adaptive change
Identify adaptive change when it’s called for
Must address it in order to turn it around (don’t just ‘let it slide’)
Confront the brutal facts with courage and openness
Get on the balcony
Create enough distance to see the ‘big picture’ of the system
3. Regulate distress
Don’t overwhelm people, but provide enough tension to maintain urgency
Challenge unproductive norms
Ask questions rather than give answers
4. Maintain disciplined attention
Identify any distractions and refocus the work
Give attention to tough issues
Expect that people are likely to slide back into old behaviours unless focus is maintained
Reframe issues to get at the heart of things
5. Give work back to people
Get others to assume responsibility
Instil confidence in people through encouragement and support
Be an active part of the change
6. Protect voices of leadership from below
Protect rather than squelch those who take the risk of speaking up
Embrace and hear all voices including dissenters
(Ronald Heifetz)
How the brain makes decisions
Being highly adaptive can be easy to say and hard to achieve. Turns out, there’s a brain-based reason for this.
Most of us are familiar with the fact that there are different systems in the human brain that affect our thinking, behaviour and reactions. While many of the 1970’s generalisations about the ‘left brain’ and ‘right brain’ function (which have crept into popular belief) have been proven to be fallacies, there are two distinct systems in the brain that contribute to the complexity in leadership and leading change.
Across disciplines, most specialists and researchers who study human behaviour, cognition and decision-making agree that there are two distinct systems or aspects of the brain. In his 2011 seminal work, Thinking Fast and Slow, renowned psychologist Dr Daniel Kahneman identified these as System 1 (the fast, habitual and intuitive system) and System 2 ( the slower, more deliberate, rational system of reasoning. Other labels and terminology to describe these two systems (some dating back as far as the 1970s) include: Affective vs. cognitive; automatic vs. controlled; reactive vs. responsive; System x (Reflexive) vs System C (Reflective) etc. The most engaging variation comes from Jonathan Haidt (a US social psychologist), who described these as the Elephant and Rider.
Our brain’s reactive system or ‘Elephant’ is focused on instinctive, automatic and habitual behaviour. -. It is rooted in the primitive survival system that was essential in the face of physical threat in the past. Designed to react swiftly, it can also often be unconstructive, as we operate based on limited perceptions, unconscious views or emotionally-fuelled assumptions about a situation. Your System 1 Elephant is also key to being able to function in the world; your Elephant uses mental shortcuts (also known as heuristics or cognitive biases) to come to quick (often unconscious) choices or decisions. . This filtering conserves brain resources and means your System 2 Rider isn’t overwhelmed by the onslaught of stimuli that surrounds you, every moment of every day.
While we need our Elephants to survive, there are some important implications associated with how this part of the brain operates:
Our cognitive biases can serve as blindspots - preventing us from seeing or hearing important parts of a situation, or from considering courses of action.
This is also the part of the brain that actively resists change and tries to keep things the same.
People often fail to recognise that their behaviour or decision-making has been affected by their System 1 Elephants because our System 2 Riders can be very good at justifying the behaviour and reactivity of our Elephants (including post-facto rationalisation). While this helps us maintain a coherent sense of self, it prevents us from mediating the impact of our System 1 and learning from decision-making experiences.
In contrast, our brain’s rational system or System 2 Rider is considered a more modern function of the brain, focused on dealing with high-level complexity, stimulating novel ideas and solutions, as well as helping us remain present, purposeful and considered in our behaviour. Our Riders take a more pro-active and constructive approach to problems and tasks, rather than the reactive approach of the Elephant (which, although helpful for survival, doesn’t always allow for abstract, reflective, purposeful and resilient thought processes).
So what do the Elephant and Rider mean for leadership and how do you engage both of these systems to bring the best out of your people in the face of complexity?
The role of the leader is two-fold: 1. Help people understand the challenge (Rider); and 2. Help motivate people to feel motivated to change (Elephant). This often involves increasing psychological safety and trust, reducing fear, using encouragement and reward, clarifying goals and using teamwork to reduce the size of the task for any individual.
The five pitfalls
When confronted with complexity there are some common pitfalls that we see leaders fall into if they don’t check themselves, lift out of Elephant and into Rider, and bring a sense of presence to their leadership approach.
These are:
1
Treating complex problems as complicated ones
Trying to exercise control or assuming there is a ‘right’ answer
2
Defaulting to ‘tried and tested’ solutions
Complex problems are contextually specific and change over time (even as you are solving them)
3
Thinking you have to solve it yourself
Complex problems can’t be solved by one person - there is usually too much information and interconnectedness. It takes groups learning and adapting together to find potential answers to test and monitor
4
Not creating a safe to fail environment
In order to lift out of Elephant/survival mode and into Rider/creative thinking, there must be an environment where people are safe to ask, try, fail and learn
5
Not looking after yourself as a leader
Your ability to solve complex problems is reliant on your mental and physical well being - making sure your own System 2 Rider shows up for the challenge. Trying to solve complex problems in 15 minutes in between back-to-back meetings with adrenaline running high is unlikely to achieve the results you are looking for
So what?
In summary, remember:
The world is changing, fast
The role of humans is to be more human and do what machines can’t
Organisations are trying to adapt, but we’ll need new mindsets, cultures, tools and skills to get there
Leaders are at the frontline of helping their people engage both System 1 Elephant and System 2 Rider and respond constructively, rather than just out of default reflex or habit
In order to do this you need to avoid some key pitfalls, look after yourself and start valuing things like reflection and questioning rather than knowing and doing
Take a minute to consider these questions in advance of your Group Coaching Session:
What is your understanding of complicated vs. complex decisions?
What challenges are you facing as a leader that are new, unknown or complex?
What are some of the important, higher stakes, decisions you and your peers make where a tension between Elephants and Riders might play out?
How can you use an understanding of these concepts to make better decisions as a leader?
Additional resources
Note: These videos are provided to build your understanding of some of the concepts covered above and are optional viewing.