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Health Care Transformation Begins With You

Souba, Wiley MD, ScD, MBA

doi: 10.1097/ACM.0000000000000534
Commentaries

Most health care transformation efforts are unsuccessful because they overlook the importance of personal transformation in enabling major systemic change. Personal transformation is about creating access to a broader range of ways of being, thinking, and acting in order to be more effective in dealing with those challenges for which conventional strategies are inadequate. As many of the changes that are taking place in health care are inevitable, mastering context is critical to transformation. In moving the organization forward, key thought leaders who embrace new ways of working together can help others recontextualize their challenges, thereby serving as important catalysts for diffusing these innovations into the culture. The ensuing improvement in performance is less the result of having learned some new concept or theory and more a function of having altered the context through which one’s challenges are understood. When individual transformation parallels organizational transformation, a tipping point is reached where there is a visible increase in organizational members’ effectiveness, a marked increase in organizational members’ impact on others’ performance, and a collective experience that work is more fulfilling.

Dr. Souba is emeritus dean and professor of surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Dr. Souba, 1 Rope Ferry, Hanover, NH 03755; e-mail: chip.souba@dartmouth.edu.

The imperative for transforming the U.S. health care system has never been more urgent, but the word “transformation” has been used so extensively that it has become abused, misunderstood, and worn out. Originally coined to refer to a process of radical change that steers an organization in a new direction resulting in marked improvements in performance, the word today is often used to designate any kind of process improvement, restructuring, or innovation. Moreover, much of what has been written about transformation has been more theory than pragmatism, more fantasy than reality.

With a few notable exceptions, most transformation efforts have failed to achieve their goals, partly because people have such an impressive capacity to resist change, and partly because the amount of change being strived for is so radical and difficult. In his landmark article, Kotter1 described the major traps that can derail any corporate transformation effort, which include a lack of urgency; an uncommitted leadership team; a vision that is unclear or undercommunicated; tolerating individuals who resist the change effort; overlooking the importance of short-term wins; and not anchoring changes in the corporation’s culture.

Organizations per se are indifferent to the disequilibrium and angst that accompany transformation. It is those of us who work in these organizations who are not immune, and we have always described the kind of transformational change that hits us squarely in the face as agonizing. Accordingly, we do not greet change with open arms, and most of us try to avoid it. Avoidance, however, is no longer an option. Intense pressure from multiple stakeholders—Wall Street, health care consumers, legislators, and payers—is driving the health care transformation imperative.

Unfortunately, the assumption that major systemic transformation naturally leads to individual transformation is flawed. The truth is that the transformation of individuals within an organization must parallel the transformation of that organization. Failure to recognize this complementary, reciprocal relationship has contributed significantly to the struggles that medical schools and hospitals encounter with transformation endeavors. Yet, curiously, the literature is lacking in the “how” of personal transformation. This Commentary strives to fill that void.

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Transforming (Reinventing) Yourself

There is nothing mysterious or otherworldly about personal transformation. Most fundamentally, it is about creating for ourselves access to a broader range of ways of being, thinking, and acting so that we can be more effective in dealing with those challenges for which conventional strategies are inadequate. In Deming’s2 words, “nothing changes without personal transformation.” Without the capacity to shift our usual (automatic) ways of being, thinking, and working together, we will default to what is comfortable when we are called to lead a transformation effort, and our results will be mediocre at best.3–6

Few of us would turn down having access to a wider range of ways of being, thinking, and collaborating, especially if they improved our effectiveness. But exactly how we expand the breadth and depth of our leadership portfolio is often unclear. We have all experienced how difficult it is to break free from and go beyond our engrained, default ways of leading. A science of transformation, however, is emerging, and it provides a useful place to start.

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Context is critical, powerful, and decisive

Mastering context is critical to transforming health care because many of the circumstances (the content) we are dealing with are here to stay. For example, the move to value-based care, population health, and risk-based payment models is inevitable. To successfully deal with this new content, we must alter the context through which we “see” and make sense of these often-gut-wrenching changes.

Context refers to a set of commonsense but hidden assumptions and beliefs that frame the way in which the world “shows up” for us. Contexts are always linguistically constructed, and we are always “used” by our context(s). Said more strictly, we always are being influenced (biased) by the conversation (self-talk) that comprises our context for whatever set of circumstances we are dealing with. Concurrently, we are also being manipulated by the self-talk that contextualizes the way we occur for ourselves as leaders in dealing with those circumstances.

Every challenge you deal with—a disruptive faculty member, mounting demands on clinical productivity, new pedagogies—occurs within a context. But unlike the content of these challenges, context is always alterable. It is always created by you, and only you, and thus is always a matter of choice. While you always “see” life through a context, you are never stuck with any particular context.

How do you create a new context? Start by separating the facts (e.g., the National Institutes of Health [NIH] pay line is 10%) from your narrative (e.g., “I’ll never get funded”). If you let your narrative (“This is impossible”) become your truth, you will be operating from a context that gives you much less power than one that says, for example: “The pay line is what it is. I have colleagues who will critique my grant to help me improve it, and I will submit a top-notch proposal.” Your effectiveness in tackling whatever situation you are faced with, no matter how vexing, is first and foremost a product of the context that is using you.

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The end target is new ways of being and acting

The source of your effectiveness in life is your way of being and your actions,3–6 which are coupled because the neural circuits in your brain that generate your way of being and those that generate your actions are networked together.7 Each of us has a “characteristic” way of being (e.g., laid back, outgoing, cautious, timid), which contributes to what we think of as our personality or disposition. Largely determined by our “connectome”7 and our early life experiences, the “way we wound up being” includes a set of coping strategies that seem to give us a certain measure of success. One of the ways we all “wound up being” is resistant to change.

During times of major change, when more and better leadership is called for, we often default to those familiar ways of being and acting that we are comfortable with. Unfortunately, they can limit our effectiveness. Some people withdraw in stressful situations, while others are abducted by their limbic system. They may raise their voice, speak disrespectfully, or send scathing e-mails. Such abortive behaviors can hamper these people’s leadership effectiveness.

Fortunately, you can transcend these automatic ways of being by enlarging your opportunity set of ways of being, thinking, speaking, and acting. Expanding your portfolio will allow you to exercise more competent leadership over a wider range of situations. Without reinventing yourself, the default (automatic) “you” that normally shows up will not be enough to successfully lead a transformation effort. In other words, until you have reinvented yourself to be free from the constraints of your past (including your past successes), you will not have the power to deal effectively with what is the source of resistance to change, either your own or others.8

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Language is the source of the transformation process

What is distinctive about being human is that our trials and tribulations are accessible through language (discourse). In other words, language is a sense-making system through which we perceive, understand, and craft solutions for our problems. Language provides us with several inextricably linked capacities that, when exercised, will make available to us an expanded inventory of ways of being, thinking, and acting.

First, language provides direct access to the different contexts we bring to the various circumstances we are dealing with. This access may be the result of self-reflection or of feedback provided by others. In either case, it is language (a conversation with yourself or others) that unveils your (hidden) beliefs and “what you don’t know you don’t know.” Once these hidden contexts become revealed, you can begin to see the inadvertent process by which they were accumulated and the degree to which they can run your life.

Second, it is by way of language that we recontextualize (reframe) the difficult circumstances we must address that call for transformation in the first place. Recontextualization also applies to the way in which we “see” ourselves. Concurrently, we must cross-examine our implicit leadership theories so as to free ourselves from the confines imposed by them.

Third, language grants direct access to the way in which what we are dealing with unfolds for us. As such, language provides access to the source of our way of being and acting. We can shift the way we make sense of our experiences by altering the words we choose to use to interpret them. Master leaders use language to alter the way in which their leadership challenges occur for them so that their naturally correlated way of being and acting enhances their effectiveness.

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Be your word

Think about the untold times you have been in a meeting where people made commitments that were either loose, vague, or never completed. It is almost as if we have an unwritten agreement that says, “If you get to it, fine; if not, no big deal.” All too often, we let people off the hook when they say they will do something, but the offender is not only the person who owns the deliverable—it is also the entire team who failed to insist on clarity and fell short in holding one another accountable. When transformation efforts flounder or hit a standstill, empty promises are a major reason.

There is no better way to jumpstart the process of transforming (reinventing) yourself than to “be” your word. In other words, a simple but powerful apparatus—the promise—propels the transformation process forward. Execution hinges on the quality of the promises we make and on the consistency with which those commitments are honored.9 Honoring your word means you never break it. If you discover you cannot keep your word, you say to those who were depending on you that you will not be keeping your word, and you clean up any muddle you caused.6

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Scaling Transformation

Successful transformation efforts always link the case for change to a compelling image of the future. People are much more willing to make painful sacrifices if they can “see” that something positive will come out of their efforts. The real power of a vision resides in its ability to inspire widespread commitment to a shared future that embodies people’s hopes and aspirations. Both the “content” of the present and the new possibilities for dealing with the present occur for us in the context of the future we are living into. When the future we are living into is about a commitment that is bigger than ourselves, it grants us the resolve and intestinal fortitude (in the present) to deal with whatever occurs along the way in fulfilling that future.

Putting together the right coalition of people to lead a transformation initiative is critical to its success.1 Key thought leaders who embrace new ways of working together are important catalysts for diffusing these innovations into the culture. By giving others reassurance that their attempts to change will not result in futility, these early adopters can play an important role in encouraging others to experiment with new ways of thinking and collaborating.10

Our “being” as human beings matters to us. Our ways of being have “care” (concern) as their fundamental mode of engaging in the world.11 The teacher’s concern is to promote learning; the concern of the scientist is to discover; the physician’s concern is to care for her patients. If we could not choose what we deeply care about, it is difficult to imagine how our being would be an issue for us at all. As humans, we are not stuck with the circumstances (e.g., a dysfunctional health care system, an NIH pay line at an all-time low) that confront us. We can deal more effectively with these circumstances by confronting the limiting beliefs and assumptions that frame them.

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Outcomes of Successful Transformation

Organizational transformation involves more than new strategies, processes, and structures; “it is distinguished by a discontinuous shift in the organization’s performance against industry benchmarks, a jump in bottom-line results, and a makeover so thorough that employees feel they are working for a different organization.”12 But more primordially, it begins with a shift in the way we experience ourselves as we deal with our challenges. If we experience our challenges as “hittable”4 and ourselves as capable, we will deal with our leadership challenges more effectively.

In contrast to incremental change, which is about revising what we are doing, transformation is about altering our ways of being. To alter our way of being, we must alter our context. In other words, transformation entails a shift in the way in which we see (experience) life—the world, others, and ourselves. As a consequence, we will deal with and interact with the world, others, and ourselves differently than most people do. Transformation does not mean that the leadership challenges in our life will go away but that, instead, we will deal with them more competently.

Interestingly, your own effectiveness will not be enhanced, first and foremost, because you acquired another skill. Rather, it will be enhanced because the perspective from which you operate has changed. A different “you” will show up. What is transformed is not you per se but the way in which you make sense of and interact with whatever you are dealing with. In other words, the ensuing improvement in performance is less the result of having learned some new concept or theory and more a function of having altered the context through which your challenges are perceived. When individual transformation parallels organizational transformation, a critical mass is reached where there is a visible increase in the effectiveness of individual members of the organization and a marked increase in organizational members’ impact on others’ performance (see List 1). Moreover, most employees feel more naturally self-expressed and fulfilled.

List 1 Hallmarks of Individual and Organizational Transformation

List 1 Hallmarks of Individual and Organizational Transformation

We all know people who are unusually effective in dealing with whatever challenge is thrown their way. What is distinctive about these individuals is not some exclusive suite of genes or neural networks; rather, what makes them special is their relentless drive to go beyond their default selves to create and unleash their best selves. We often call these individuals leaders. They have mastered a distinctive language of leadership, which enables them to lead themselves, others, and their organizations with grace and acumen. This is transformation.

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A Mountain With No Top

Although transformation can imply a progression with a beginning and an end, it is actually a never-ending process, a mountain with no top. Individual and organizational change must go hand-in-hand; they are constantly in a dynamic tension. Deans and CEOs must keep enough tension in the system to maintain the threshold of learning, while recognizing that there is a limit of tolerance beyond which people’s capacity to handle more change is compromised. This is critical because it is our ability to learn from our current challenges that best predicts our success in tackling future challenges. People in learning organizations experiment, take risks, and harness the organization’s collective wisdom to create new and better ways to be effective.

Everyone is committed to something. Even people who are committed to beating the system or just getting by in life can have strength of conviction. In that sense, we are all taking a stand for some future. The real difference is whether or not the future we are committed to is bigger than we are. Only a personal stand for a future for health care that is bigger than you are will enable the kind of transformation our health care system must undergo. Accordingly, health care transformation begins with you.

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References

1. Kotter J. Leading change: Why transformation efforts fail. Harv Bus Rev. 1995:59–67 March–April
2. Deming W Out of the Crisis. 1986 Cambridge, Mass MIT Press
3. Souba W. The science of leading yourself: A missing piece in the healthcare reform puzzle. Open J Leadersh. 2013;2(3):45–55
4. Souba W. A new model of leadership performance in health care. Acad Med. 2011;86:1241–1252
5. Souba WW. The being of leadership. Philos Ethics Humanit Med. 2011;6:5
6. Erhard W, Jensen M, Granger KSnook S, Nohria N, Khurana R. Creating leaders: An ontological/phenomenological model. In: The Handbook for Teaching Leadership. 2011 Thousand Oaks, Calif Sage Publications
7. Seung S Connectome: How the Brain’s Wiring Makes Us Who We Are. 2012 New York, NY Houghton Mifflin Harcourt
8. Goss T The Last Word on Power: Executive Reinvention for Leaders Who Must Make the Impossible Happen. 1995 New York, NY Crown Publishing
9. Sull D. Closing the gap between strategy and execution. MIT Sloan Manage Rev. 2007;48(4):31–38
10. Rogers E Diffusion of Innovations. 20035th ed. New York, NY Free Press
11. Heidegger M Being and Time. 1962 New York, NY Harper & Row
12. Pascale R, Millemann M, Gioja L. Changing the way we change. Harv Bus Rev. 1997;75:126–139
© 2015 by the Association of American Medical Colleges