Prior Management Moment columns have discussed the practice of leadership in public health agencies.1,2 Also, a number of columns have focused on the major challenges and opportunities faced by public health organizations as they attempt to become more “informatics savvy.”3,4 Central to leadership in any area of public health, and particularly in the field of public health informatics, is the ability to imagine a desired future state and then to inspire teams to achieve that future.
If we in public health fail to imagine a desired future state, for whatever reasons, this chain of events from imagination to inspiration to realization of the vision will not be initiated and propagated. In this column, we explore a tendency, which we characterize here as a “collective failure of imagination,” by attempting to identify underlying causes and manifestations and then to offer a few suggestions to overcome this limiting pattern of organizational behavior.
Context and Recognition
Within the public health informatics space, the technology side of innovation is often the easy part. In many public health agencies, resistance to change in information system modernization (particularly rapid, substantive change) may emerge at times, manifesting as reluctance or even hostility toward new ideas. Within this context, a collective failure of imagination may take on many forms. Two forms that we have seen are negative forecasting and responsibility avoidance.
Negative forecasting is simply a listing of all of the reasons why something new will not work. Responsibility avoidance (ie, “it is not in my job description”) may also further impede the process of innovation and change. These forces lead toward risk avoidance in public health agencies and may stifle innovation. Fear of loss, fear of gain, and fear of change may underlie these forces.
Addressing Forces of Resistance
Everyone deals with change differently. Some embrace it. Some openly thwart it. Many ignore it or wish it would go away until they are “ready,” which means until it feels more safe, less threatening. The cumulative result is significant pressure to maintain the status quo within public health organizations. It is as though there is a collective voice in our heads that says “Be careful! Slow down! Don't try things that might not work!” Author Steven Pressfield calls this state of mind the resistance, and as he describes it,
Our enemy is not lack of preparation; it's not the difficulty of the project or the state of the marketplace or the emptiness of our bank account. The enemy is our chattering brain, which, if we give it so much as a nanosecond, will start producing excuses, alibis, transparent self-justifications and a million reasons why we can't/shouldn't/won't do what we know we need to do.5
The paradox of the resistance is that what feels safe is actually risky and what feels risky is actually safe. Let us take an example of public health informatics. Some have argued that new ways of collecting information will not work for public health because the current workforce does not yet have the skills needed to adopt these new approaches. So, instead of exploring new approaches, we invest our time and resources into techniques that we have used in the past. After all, there are many ways to move data from point A to point B, and if all we care about is transporting information, then the method chosen does not matter much.
Yet, if we take a step back and look at other factors, then defending the status quo becomes untenable. In the health informatics domain, it is particularly worth considering questions such as “What standards have staying power and which ones are being phased out?” “What standards are companies such as Apple, Microsoft, and Google using?” “What standards have attracted vibrant, open-source communities?” “How can public health organizations tap into API-based infrastructure that has already been built and is freely available, so we don't have to reinvent the wheel?” “How can public health agencies contribute to emerging standards that align well with our needs?” “What happens when all of the people who are well-versed in the old standards retire?” “How will public health attract the workforce it needs if the methods we have chosen to adopt require highly skilled people to learn out-of-date technologies that are not transferable to other contexts?”
As you consider these questions, it is likely that “the resistance” will rear its head and draw out fear-based responses. The question then, as author Seth Godin6 points out, is “What do we do with the fear? Do we succumb to it? Do we try to battle it out? Or do we embrace it as part of our collective journey and use it as a compass to help guide us toward a new future for public health?”
Imagination is the antidote to “the resistance.” And, when delivered in mild inoculatory doses, it can help change the culture of an organization. Those in leadership positions must cultivate the “dreamers” whose collective imagination can point the way to a desired future. At times, the practical orientation of public health professionals may be a barrier to encouraging creative thinking. Comments such as “how would this work” or “didn't we try something like this before that didn't work?” or “we don't have the resources” may diminish the desire or impetus for creative thinking. As these predictable sources of resistance emerge, a test can be applied to the process of moving from imagination to realization of change. The key question becomes, “if this idea works, what will we see happen?”
Once the benefits of new approaches become clearer and more concrete, it is possible to abandon old assumptions and experiment with new ways of approaching public health challenges. Often, it is useful to bring in experts from the outside, such as an Entrepreneur-in-Residence or a distinguished fellow, who are empowered to take calculated risks and who can help nudge more traditional employees out of their comfort zones.
Embracing Creative Tension
In Peter Senge's7 classic book, The Fifth Discipline, he advocates for leaders to embrace a creative tension between current reality and a desired future state. Holding creative tension is central to the practice of personal mastery—one of the 5 core disciplines of effective system thinking. He provides a metaphor for holding creative tension by demonstrating the effect of holding a rubber band between 2 hands, with one representing the vision and the other representing the current reality. Leaders must then regulate the level of creative tension to adapt to organizational reality and sources of resistance to change.
Within public health organizations, leaders can support those who are most open to change and are willing to dance with the tension of “this might not work here but it's worth trying to see what happens.” These early adopters are often less fearful of taking risks and are more comfortable with “failure” because they know that “failure” is part of working within this tension. They can provide much needed “social proof” to help motivate others within the organization who have a high need for certainty before they are willing to deviate from the status quo.
To help incentivize a growth mind-set within their organizations, public health leaders should embrace “not knowing” as a core competency and encourage employees to indulge their curiosities. Tapping into intrinsic motivations in this way will help prepare public health agencies to take on more complex challenges wherein a clear path forward has not yet been defined.
In another seminal book, Turn the Ship Around, former Navy Captain David Marquet8 tells the true story of what it took to turn a failing nuclear ballistic submarine into a top-performing organization that produced leaders at all levels. When he took over the USS Santa Fe, Marquet vowed to stop giving instructions and instead focused on clarifying his intent. This distinction helped turn his crew from disgruntled employees who just did what the boss said to proactive, passionate, and creative people who took initiative. He created this change by creating an environment that valued technical competence and organizational clarity and then delegating decision-making authority to the people on the front lines. This helped foster a sense of psychological ownership at all levels of the submarine, in which everyone shared responsibility in discovering the answer and had a vested interest in the success of the organization.
Another approach to organizational transformation is articulated in John Kotter's9 book, Leading Change. Kotter lists 8 steps that organizations can use to foster innovation and creativity and recommends that leaders articulate a sense of urgency as a starting point for change. Other steps in this tested model build upon this initial step. To help facilitate organizational transformation, public health leaders can form mastermind groups, which are small groups of individuals with growth mind-sets who meet regularly to explore new ideas and hold one another accountable as they adopt new approaches.
Questions for Leaders to Ask
Within the area of public health informatics, leaders now recognize an extraordinary sense of urgency for which organizational change is needed now more than ever before.4 In addressing the dynamics that are described in this column, leaders can ask a few questions as tools for overcoming a “collective failure of imagination” that may limit success in a public health agency:
- When you look at your organization, which employees are learning new things and sharing their understanding with others? Which are merely following orders?
- How are you nurturing and empowering the voices of change and their creative imagination in your organization?
- How comfortable are you at giving up control to help create and empower leaders throughout your organization?
- To what extent are you fostering or embracing “not knowing” as a core organizational competency?
- In medical education, the “see one, do one, teach one” pedagogy is the traditional method of teaching surgery. How might you use a similar action-oriented approach to help foster innovation and creativity in your public health organization?
- What opportunities do you see to form mastermind groups with your peers or to help facilitate the formation of mastermind groups across the public health ecosystem?
As leaders embark upon a change initiative, certain predictable barriers emerge including what may be considered as a “collective failure of imagination.” By encouraging the “dreamers” in the organization, embracing creative tension, and adopting a proven approach to leading change, these barriers can be addressed and innovation promoted in public health agencies.
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2. Baker EL. Leadership and management—guiding principles, best practices and core attributes. J Public Health Manag Pract. 2014;20(3):356–357.
3. LaVenture M, Brand B, Baker EL. Developing an informatics-savvy health department: from discrete projects to a coordinating program. J Public Health Manag Pract. 2017;23(3):325–327.
4. Brand B, LaVenture M, Lipshuttz JA, Stephens WF, Baker EL. The information imperative for public health: a call to action to become informatics-savvy. J Public Health Manag Pract. 2018;24(6):586–589.
5. Pressfield S. Do the Work: Overcome Resistance and Get Out of Your Own Way. Black Irish Entertainment; North Egremont MA. 2011; pg. 22.
7. Senge P. The Fifth Discipline: The Art and Practice of the Learning Organization. Random House; New York. 1991.
8. Marquet LD. Turn the Ship Around!. Greenleaf Book Group Press; New York. 2012.
9. Kotter J. Leading Change. Harvard Business Review Press; Cambridge MA. 1996.