Navigating Turbulence in an OHT Climate
Leading in Complexity
August 30, 2019
Navigating Turbulence in an OHT Climate

“The greatest danger in times of turbulence is not the turbulence; it is to act with yesterday’s logic.” - Peter Drucker

As a health care leader, you’ve known for a long time that decisions about the health of local populations need to be made at a local level. You also know how critical it is for local health service providers to work together to create a seamless experience for patients. You’ve been working toward this, advocating for it, for years, decades even. As our political climate swings between the polarities of left and right you’ve been adapting, changing, flexing as best you can in the organizations you lead, trying to deliver on this mandate. But this latest swing is something different. It’s not just a swing back to centralized authority, although on the surface it might look like that. It’s a move that attempts to centralize administration even as it de-centralizes leadership and accountability.

Saving on administrative costs while distributing decision making and accountability is a profound integration of approaches and one that will require new thinking, new skills and new structures to implement successfully.

At Instincts at Work we’ve been evolving leadership thinking to realize the performance gains in this approach for years and the teams we have worked with are showing their readiness for such new approaches.

But based on conversations we’ve been having recently, it’s clear that we need to pay close attention to ensure we don’t “act with yesterday’s logic.”

Two traps we are prone to are:

We lay them out here in the hopes that you’ll be able to recognize them when and if you encounter them. Please note that this is a fictional scenario comprised of typical reactions that we have witnessed from working with dozens of attempted collaborations over the past decade.

OHT meetings are progressing. Leaders are getting together and discussing what types of accountability and governance structures to propose in their application. One of the leaders of the local hospital knows a consultant who specializes in governance so he proposes that he will contact his consultant and skip the usual RFP process because of the short timeframe and the engagement being below the minimum requirement for the hospital.
Although the hospital leader may be genuinely seeking to benefit the group as a whole by being expedient, the other members of the OHT committee interpret the move as a power grab and start to assume that this is the hospital’s way of controlling the process. The community partners react by claiming that the hospital leader is being unfair and not inclusive, and faction groups start to form and threaten to withdraw from the collaborative if the hospital doesn’t become more inclusive.

This kind of scenario is very typical as individuals work through the complexity of uncertain peer motivations and develop an understanding of what it means to work together to negotiate the wants and needs of multiple, equally important, stakeholders.

Underlying these traps are a set of unconscious assumptions. If we aren’t deliberate about examining them and the impact of blindly acting on them, we risk undermining trust as we engage in more broad collaboration:

If one organization is viewed as having more skills and resources compared to another one organization usually has the sense of an imbalance of power. This can lead to the assumptions that power is being abused. Members who feel less status relative to other team members will often interpret (accurately or not) that the higher status member is taking advantage of the situation to protect their own power base. Such a perceived power asymmetry leads to the perception of a power grab. Leaders from high status organizations are often bewildered by this response from others as they see themselves as shouldering the burden of the performance and accountability.

What is the remedy?
  • It is helpful in these circumstances for members to be aware of and able to name subconscious status threats. Then we can shift the potential conclusions that we make about each other as we try to equalize perceived power imbalances.
  • Going slow, asking members for permission, acknowledging the value in the diverse skills, resources and contributions of all members can help to mitigate the threats that often undermine our best efforts at building the trust needed for collaborative relationships to grow.

Generally, leaders who are invited into partnerships and collaborative working relationships with other leaders have been successful at achieving results in their individual organizations. These leaders have often developed an identity and find a source of pride (and status) in being a leader who achieves results.

Note what happens when this leader steps into an arena with other leaders who experience varying levels of power asymmetry as described above, as well as varying amounts of goal directedness: Many healthcare organizations have a core value of making sure everyone in the organization feels listened to, and included which can run exactly contrary to our results oriented leader’s need for task completion and goal achievement. This tension between results and relationships is one that will need to be continually managed as we work together in OHTs.

The felt need of the hospital leader in the scenario above is to get the job quickly and cost effectively done which of course is central to the group’s success. Unfortunately, it can also create a threat response since the need to achieve often feels contrary to the values of group inclusivity mentioned above. Without strong coaching and facilitation skills and strong emotional sensing this dynamic inevitably results in ‘back room politics’ or worse, the forming of splinter groups for the sake of expediency as individuals seek to negotiate values that are in apparent conflict. In such cases, trust is quickly eroded.

What is the remedy?
  • To avoid failing in these predictable ways as we attempt to build governance structures to enable OHTs, we must learn new peer-based skills for creating accountability and resolving problems sourced in power imbalances, different priorities and values and trust. Increasing the level of difficulty, we need to do all this in non-hierarchical partnerships between peers which means we can’t resort to traditional authority structures to break stalemates and make decisions.

The skills we need to master are:

Going slow, asking members for permission, acknowledging the value in the diverse skills, resources and contributions of all members can help to mitigate the threats that often undermine our best efforts at building the trust needed for collaborative relationships to grow.

When we begin to work together as peers the different access to skills and resources can show up as felt power differences between peer organizations. When we don’t recognize and own our own power in such situations, we can feel at risk and resort to ineffective fight, flight or freeze responses. Learning to identify threat responses in ourselves and in our teammates and handle them in ways that increase engagement and build trust is an essential new suite of competencies for operating in coalitions of peer organizations. Additionally, organizations who are used to having easier access to skills and resources through large organizational structures often forget what it’s like to operate in lean environments. This can lead to a lower sensitivity to the needs of smaller organizations, or frustration with the pace at which they need to work to conserve energy and resources.

In Loonshots: How to Nurture Crazy Ideas, Cure Diseases, and Transform Industries (2019), author Safi Bahcall notes that there is a Magic Number ‘M’ which is the size of the organization at which this shift from focus on achievement to a focus on self interest happens. He also points to the formula for increasing the M number not just via culture and clarity of purpose but also through the structural design of the organization. This understanding has important implications for OHT governance design. The purpose and organizational design of OHTs are powerful contextual cues that can release or limit our collective performance in service to the vision. We need to resist the lure of expediency and getting things checked off our list and take the time to ask deep questions to ensure we get the essential design right; the most important of which is accountability to the population that the OHT is designed to serve.

With an increased focus on accountability in OHTs it becomes increasingly important to understand what accountability looks like and what it means in a context of distributed leadership. Again, our long history in hierarchical organizations does us a disservice as we’ve grown used to using external pressures to attempt to force accountability in various ways. A new understanding of accountability shows it to be an emergent property of committed individuals working together through trusted relationships toward an outcome they all care about. In truth, accountability is always voluntary, though it can be encouraged through the skillful application of coaching and facilitation skills in what we call an “approach culture”. In an approach culture all members are able to sense when others are fearful or feeling at risk and they can apply coaching or facilitation skills as needed to re-engage them. Although the conversations may appear difficult or conflictual to the outside observer, team members are willing and able to engage in in those difficult conversations and know the value of productive conflict in building trust and accountability.

As OHTs innovate to achieve accountability and performance metrics we will all need to know how to have powerful growth conversations with our peers and staff. We need to become adept at conversations that encourage risk taking, build determination and champion the willing adoption of new practices, learning and development. Coaching and facilitation skills are uniquely suited to uncovering the unspoken emotions that derail these important conversations and attempts at innovation. We all need to be able to support and challenge one another to step over our individual growth edges. Coaching and facilitation skills help us do this well. As we develop new skills to move us beyond known ways of operating, we need supportive environments to help us successfully navigate the turbulence.

Oversized purple curve.Oversized green curve.

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