Organisations as thought leaders; some healthcare examples

Thought leadership is not just about individuals. For many organisations, their mission is to be the thought leader in their sector.  I’ve listed below the healthcare related organisations that I believe to be thought leaders.

·     The Health Foundation  in London practices a pragmatic and sensible thought leadership. They base their knowledge around programs of work, linked the more academic reviews. They share knowledge very well and a great example is their work on Self Managements where all the materials can be accessed, free of charge, including train the trainer packs.  They take on new ideas and put them to work in programs. They are prepared to take risks and their work is subject to evaluation – which is also shared.  They are a charity so have no need to sell – and this shows.

·     The Kings Fund, London,  is a traditional thought leader for healthcare. They’ve moved into blogs and videos, and other social media platforms such as Twitter, Facebook and LinkedIn, as a means to share their news and views – and to help others connect. They are best loved for the discussions they hold. These are tough questions with a wide range of people taking part. They empower thought leadership in others, which is very magnanimous of them.

·     The Nuffield Trust is another UK based organisation which is a thought leader, in a fairly tightly packed thought leadership arena. They are probably best known for their sharp and necessary evaluations and reviews of policies and programs. They are trusted because they are independent and not in anyone’s funding pocket. They do blogs, publications, videos and some excellent charts.

·    The Institute for Healthcare Improvement  in Boston.  This is a well-known organisation for its work in developing strategies for improvement and in bringing together groups of interested people to share. Like any organisation, they have something to sell. However, they are quick to share new ideas in white papers and make many of their materials available to anyone, free of charge. (excepting their conferences which are notoriously expensive).

i    The other articles in this series are:

1. What or who is a thought leader
2. Being a thought leader

Being a thought leader

This is the second article in the series. The first article was "What or who is a thought leader".

Gandi had a saying that you need to "Be the change you want to be". So if you want to be a thought leader, you need to be one. Obvious, yes? No, it isn't. I know some people who call themselves a fisherman but fish only once a decade, or they say they are a writer of novels, but they've yet to do more than the first chapter. To be a thought leader takes effort and invest in being one.

Leadersdirect  point out the need to invest in your own knowledge if you want to have followers and be considered as a thought leader:

"To be a thought leader, you need to immerse yourself in your professional domain and search for new things to say that add value to your organization's objectives."

Fastcompany  has an excellent article on the golden rules for being a thought leader from an organisational perspective:

1.       Don’t sell anything except ideas

2.       Always give it away

3.       Have a unique perspective

4.       Focus on one thing at a time

5.       Address a specific audience

6.       Admit what you don’t know

7.       Make your audience feel smarter

8.       Hire thought leaders

The same article also covers the need to thought leaders to be thoughtful, and patient, leaders.

Thought leaders are not people who lie on the sofa dreaming up new ideas (well, not all of the time, anyway).

TheCEOOnline  has a great article on the 9 essential skills for thought leadership, and the graphic below is from them. I recommend you read the whole article and use it to assess your own position as a thought leader.

Who or what is a thought leader?

This is the first in a series of posts about thought leadership.  I started by thinking about the "what" of thought leadership. It's a concept - what does it mean?

Wikipedia suggests that

"The term was coined in 1994 by Joel Kurtzman, editor-in-chief of the Booz Allen Hamilton magazine, Strategy & Business. "Thought leader" was used to designate interview subjects for that magazine who had business ideas that merited attention."

Forbes has an excellent blogpost on the topic and helpfully distinguish between what a thought leader is, and isn't. They have parts to the definition of a thought leader:

“Definition—Part One

A thought leader is an individual or firm that prospects, clients, referral sources, intermediaries and even competitors recognize as one of the foremost authorities in selected areas of specialization, resulting in its being the go-to individual or organization for said expertise.”

To me, this suggests a thought leader is someone who is recognised as such by their followers. Obvious when you think about it.

“Definition—Part Two

A thought leader is an individual or firm that significantly profits from being recognized as such.”

Ouch, this wasn’t quite so obvious, but it makes sense. Behind every thought leader is an intention, a purpose and a bias.

Leadertoday.org suggests that 

"Thought leaders are people who have an influence on how people think about an issue or situation. Through their development of models, theories or ideas, they end up with a following that stems largely from the apparent truth and/or usefulness of their ideas."

That makes sense and I like the bit about influence, and specifically that this influence is balanced with “truth” and usefulness of ideas. Though I suspect truth and usefulness are dependent on a point of view which means some people will not agree with a thought leader’s ideas. So a thought leader can be a leader for some and a non-leader for others; it all depends on the followership’s point of view.

Leadersdirect  have a good description of what a thought leader is. They mention

“Kouzes and Posner base their view of leadership on the metaphor of a journey. Their leaders sell the tickets for the journey AND help followers reach the destination. By contrast, thought leadership merely sells the tickets for the journey, leaving it to others to get to the destination on their own or with the help of managers, coaches, facilitators and catalysts.”

I like the way this separates thought leadership from organisational leadership, though I do wonder whether “regular” leaders can also be thought leaders, and vice versa.  I also wonder how many “tickets” are sold to journeys that are never taken.

The next quote from Leadersdirect I really like as it democratises thought leadership. You don’t have to be in a specific position to be a thought leader. It is about “distributed thought leadership”.

"Whenever you advocate a new idea to your colleagues or boss, you show thought leadership. It isn't necessary to have inspirational influencing skills, which is necessary for senior executives because they need to win over the entire organization and beat off their internal competitors for top jobs. Also, to initiate organization-wide change, it helps to be inspirational. But a thought leader can focus on smaller scale changes - ideas for a new product or changes to an existing one. Thought leaders can persuade others using logic, evidence or an actual demonstration of a prototype to win support."

In summary, a thought leader is:

• anyone who chooses to influence on a specific topic
• who doesn't have the responsibility to implement the ideas
• who is recognised by others as having influence on a specific topic
• who has something to gain from hereir influence

Do you agree? Anything to add?

#thtldr

Consistency of leadership matters

No matter what "evidence" you seek, leadership is always in the top ten of factors necessary for change and transformation of systems of care - or any system for that matter. There are books, papers and reviews all trying to qualify the type of leadership that works well.

I've been asking myself whether length of time in a leadership role makes a difference. When I look about me at the organisations who are held up as role models for good organisational processes, good collaborative working and good results - most often the leadership team has been in place for many years. Not just one leader, but at least 2 or 3 of the team.

Perhaps it important just to be there to hold the history and to maintain some form of continuity. Doing this while everything changes around you means the good leaders are naturally those who learn to adapt themselves  and their organisation, to the changing context.  I suspect they don't have great charismatic abilities, not do they espouse clever theories - they just get on with the job - year by year.

I applaud that level of commitment.

Book Review: Crucial Conversations by Patterson, Grenny, Mcmillan & Switzler

This book has the subtitle "Tools for talking when the stakes are high" and I found there was not a single page that disappointed me. Part way reading through the book I thought this is all common sense, and of course a lot of it is. However, the authors are showing and telling in an extremely compelling manner that you just can't help going "aha", oh-yes", "of course" every few minutes. My copy is full of notes, highlighter marks and pages turned over.

So what's the meat in the book?

At its heart is a dialogue model which is about me and the other and how we each act, feel, tell a story and see/hear. In our dialgue we are aiming to create a pool of shared meaning and there are a number of factors that impact this, such as safety, and silence (withdrawing, avoiding, masking) and violence (controlling, attacking, labelling). All this sounds cold in this description, what brings this book alive is the way the authors develop the model with the use of various tools and stories. It's impossible to read it anot feel connected yet at the same time feel empowered to do something about your next high stakes conversation.


You can download book chapters and sample MP3 audio from http://www.vitalsmarts.com/books_more.aspx . There is also the stress test to discover your style under stress.

Book Review: Time Traps by Todd Duncan

You can't manage time but you can manage your thoughts, actions and tasks - that is the underlying premise of this powerful book. I read the book a couple of years ago and in a rare moment, I decided to read it again as I found I was often using the mantra of its premise and was seeking to find more ways to satisfy my desire to get a grip on the slippery slope of the balance between time and tasks.

The book is written with sales in mind though I didn't find this detracted at all from my personal context and I expect anyone who deals with many interactions with others will find it helpful.

The author talks the reader through a number of traps. The first is the identity trap. This is how when time is monopolised by our work we become our work - and thus how important it is to rethink time, to rebalance as part of regaining our personal identity. Secondly there is the organisation trap where the author suggests that most sales people are disorganised, out of control and say they lack the time to catch up. Well, that sound like a lot of the stories I hear from many people! And what I say sometimes as well!!! He suggests learning to stop all unnecessary tasks before they steal time, admit legitimate tasks onto your list of things to do, and make sure you know the difference between necessary and productive tasks. Then take action and assess how you're doing.

He also talks about the Yes trap, and then how to say No, or sacrifice more sales for the benefit of others. He has some interesting things to describe on the value of saying no. Then there is the Control Trap and the issues of letting go and learning to delegate. The technology trap should be familiar to those caught by their email, and for sale people he discusses the Quota trap. And if you're not trapped out yet, there is also the Failure Trap and the Party Trap.

I know this book changed how I felt about time and the management of it the first time I read it and certainly, the second time around, I was reminded to take some more detailed action steps.

Go to here http://www.timetrapsbook.com/ to download a chapter or to carry out the self assessment on the eight traps.

Paper: Developing capable QI leaders

A paper for those who have the pay-for access... Cincinnati Children's Hospital have been running cohorts of leaders through 6-month programs. The results look impressive, with two thirds completing their QI projects and a third of those involved presenting their project work at conferences.

BMJ Qual Saf. 2012 Jul 12. [Epub ahead of print]
Developing capable quality improvement leaders.
Kaminski GM, Britto MT, Schoettker PJ, Farber SL, Muething S, Kotagal UR.

Book Review: You can't order change: Lessons from Jim McNerney's Turnaround at Boeing - Peter Cohan

I was attracted to this book because the title said what I have always thought yet doesn't seem to be what I get involved with doing! I spend a lot of time on Boeings so I felt I had an interest in knowing what they doing and how they are doing it.

A while back Boeing was in a mess - stockprice was down, staff were complaining, revenue was not as anticipated, key people were leaving, lawsuits abounded and generally everything was on a downward trend.  Enter CEO Jim McNerney who gained a reputation of requiring results to speak for themselves rather than putting himself on a pedestal.

This book takes you through the CEO perspective and actions in turning around a self-destructing monolith. The view I got form the book was the importance of people stuff, relationships and leadership in times of trouble. Sounds obvious but in my experience I see organisations go down the route of more rules, process redesign and the like when the crunch hits.

Cohan interprets McNerney's approach as expressing what is required from leaders in the organisation, working with people so they jointly own these leadership attributes and encouraging communication at all levels. He also got rid of the people who didn't make the grade while investing in those who were growing into leadership roles with the right skills and capabilities. After people, the big message is the importance of the person who manages the finances. Then there is also the piece about customer involvement.

Written in summary here all this looks like the standard stuff of management and leadership texts. However, Cohan does explain all these actions in the context of Boeing. Still - to me, much of the diagnosis ended up a bit samey. Maybe that is more a reflection of my expectations - was I looking for something unique? Maybe the answer to large scale change in large organisations really is simple - the difficulty is in applying the tactics.

Overall - nothing new in here and maybe that is what is new.

Coaching, feedback and behavioural tools - MBTI

So what tool or method do you use for your coaching practice or other organisational and improvement work?

Over my career I've been on the receiving end of a number and also tried a variety with different clients.  I've ended up using MBTI (Myers Briggs Type Indicator) as my main method for helping others - to help themselves. My main reason is this tool is well evidenced, has been in place for decades and is used successfully in many countries. The evidence base is important for me as I believe it is necessary for healthcare to demonstrate the use of evidence-based techniques and tools.  The techniques can't be administered or debriefed unless you've been accreditated which means there is a consistent standard world-wide.

Other reasons I prefer MBTI:

• it is more than a one-off
• it can be scaled from individual through the team and organisation
• it works well to support change processes
• the evidence base, being huge, allows greater depth of understanding
• it is common enough that it provides a "language" for staff to use in times of difficulty

Do you know of or use other behavioural techniques which have an evidence base similar to MBTI and can also be scaled up in their use?

Book Review: Sway; the irresistable pull of irrational behaviour by Brafman & Brafman

Irrational behavour? Me? Never!

The Brafman brothers write a compelling story of how irrational our behaviour is in a variety of circumstances. While most of the book is well evidenced they bring each of the issues alive with stories that make sense - perhaps too much sense.

I'm getting a bit tired of the constant use of the airline industry as a safety example. So it was with interest I read through the case study on the crash at Tenerife which was one of the largest loss of life incidents. The authors demonstrate how the perception of loss played an important part in the creation of the incident.

Next up is a football team in the US which managed to beat all the major players but relinquishing their commitment to the predominant method of play. The story here is about how our commitment to a certain way limits our opportunities for growth and advancement. The authors show how loss and commitment add together to become a powerful irrational pull.

The chapter on value attribution is quite scary. They use a number of examples. One is of a famous violin player dressed casually playing complex tunes in an underground station during rush hour. hardly anyone paid him any notice at all. Yet some would pay large sums of money to hear him play on stage dressed in his dinner suit. The book is worth the read in this chapter about the discovery of a human fossil and how scientists of the day were not prepared to give it credence because the discoverer wasn't "one of them".

If you are currently either interviewing people for a job or going for interviews yourself, then the next chapter which looks at how initial diagnoses or decisions sway our long term responses to individuals.

Perceptions, beliefs and context come under scrutiny in the next chapter. If you want to understand why the USA has a Bipolar epidemic then read about it here. If you are involved in training and developing individuals then the examples of belief are important to understand.

So what is fairness? Read on to discover the importance of context.If you think monetary incentives are a motivation to change behaviour then the next chapter provides some examples which may rattle your thoughts. By now I was beginning to understand just how irrational we are as human beings. And just when I've grasped a bit of my own irrationality, the authors move onto the irrationality of groups, particularly looking at blockers and dissenters.

If you are wondering why no-one is following your instructions, why it is too difficult to plan something, why you always seem right and no-one else wrong... etc. then I thoroughly recommend this very readable book. It is an easy and relatively quick read (once - I had to reread to make sure I grasped what was being said).

Readiness for spread, dissemination, scaling up

Spread, scaling up, dissemination, diffusion - whatever you want to calls it - does NOT happen in healthcare in the automatic "tipping point" way of Gladwell.  This is largely because in healthcare, the NHS being one great example, the desire to spread is a top-down prescriptive one - which is most companies would be dealt with a a large scale implementation project.  Similarly, just focusing on how to describe and communicate  the innovation is not enough. (I've written about this in previous posts.)

Whatever you call it and whatever methods you use, there is evidence that there are some key factors which need to be in place before you set off on a large scale "thingy".  These are not clever, and, in fact, are annoyingly obvious. Obvious does not mean simple.  You already know about the list below and one major step forward in your large scale work is to examine why you're not working on these "readiness" factors.

1. Strategic focus: if the imitative is not named and talked about in the organisation (and team) level as a strategic piece of work to do, then it's probably not a large scale change or one which will be given priority
2. Executive sponsor: who in the organisation is responsible and accountable for the implementation (not the planning) of the change?
3. Day-to-day leadership: is the initiative being talked about?
4. Spread aim: is there a clear aim and method of measuring progress for spread / scaling up?
5. Spread / scaling up Plan: is there one? Is there one that scales down each level of implementation?
6. Costs: are the costs of the change clear? DO they include the staff time coasts? Is there an agreed ROI for the scale up?
7. How will fidelity be ensured? (Fidelity = what is scaled up / spread is the same as the initiator project)

Some references:

(There are many references available in peer-reviewed papers, however, as many of you have complained you don't have access to these, I have listed some more general and open access references. If you know of other easy access references then please comment on this blog.)

• IHI: A framework for spread
• Agency for Healthcare Research & Quality: Innovation readiness for spread
• Some of my books: Rolling out your project includes a whole section on diagnosing readiness for change. 

Leadership, Spread, Adoption & Sustainability

Here is a summary of some blog posts I've written with healthcare leadership in mind:

• Do middle managers matter in healthcare? (refers to a peer-reviewed paper)
• Why don't we search for evidence? (Importance of role modelling)
• Is the role of the organisational champion effective? (Refers to peer-reviewed paper)
• Leaders need to be productive (Video)
• Scheming virtuously: A handbook for public servants (links to the handbook)

Leaders need to role model "Spread"

If asked what the one thing leaders can do to better enable the spread and adoption of good practice in their organisation, it would be - "Be a role model".

I wrote in this blog on this topic back in May: "Why don't we search for evidence."

It's no good leaders exhorting that their staff need to adopt good practice and to use "evidence" if they don't do the same.  There's no quick fix. There's no substitution.

Next time you wonder why it is your staff don't search for, adopt or actively spread known good practices, then ask yourself when last you searched for or adopted a good practice.

Do middle managers matter in healthcare improvement?

There are libraries full of research and case studies on how doctors (and increasingly other health professionals) as well as executives, influence the implementation of healthcare improvement and innovation.  Middle managers, the cream in the éclair (often squeezed out) have not been in the headlines. But there is a new paper out which looks at their role and its importance. More research is needed.



Implement Sci. 2012 Apr 3;7(1):28.
Uncovering middle managers' role in healthcare innovation implementation.
Birken SA, Lee SY, Weiner BJ.

Managing the legacy of your project

Ending a project is as chaotic an affair as the start up. After the flurry of the beginning and the more measured stage of making progress, we are then faced with wrapping things up.  So what do you want to have as the legacy from your project?

Mostly it's all about figuring out how to keep the website going, debating where to put the useful resources that have been developed, and managing the process of celebrating results and saying goodbye to project teams.  But is this enough?

Project outcomes are good - and always worth advertising.

But what is your legacy? By legacy I mean the long term, sustainable, "thing" that has resulted form your program. Sometimes this isn't seen clearly until years later. There's an excellent paper I commend you to read which covers the difference between people, process and product legacies.  I particularly like the "reuse" concept.

Why don't we search for evidence?

So I'm perplexed.

I've spent years listening to leaders at all levels - from unit, to department, to organisation, to region, to National  - all say they want "other people" (usually those "beneath" them) to adopt existing good practices.

That's all good and well.

But when I press these leaders on what efforts they've made to check the literature, search for existing guidelines or consider the experience of people similar to themselves - they all look at me blankly.  One recently told me that "that sort of thing is for the people who need to improve, not me. They need to adopt guidelines."  When I pressed him about the opportunity he has to learn from others in the design of his large scale intervention, he replied "We're different."

I shall invest a new piece of equipment - a mirror.

Is the role of an organisational champion effective?

The label "champion" is a complex one to wear and one which I've been a bit cautious about recommending anyone use.  In the UK, it's been common to identify that enthusiastic doctor or nurse, label them the champion for the work and then expect them to get on and lead the changes.  Sometimes this works, and sometimes it doesn't.

There's a really interesting paper published (by Hendy & Barlow, Imperial College, London) which examines the role of the champion and their effectiveness in one program in the UK. I like this research because it is lengthy (three years is a long time) and ethnographic. Their bottom line, it seems, is that it's good to be a champion in your own patch, but as soon as you're expected to deliver your champion role outside your regular context, then the effectiveness drops off. This is instinctively logical but all the same it's good to see some research on the topic.

Soc Sci Med. 2012 Feb;74(3):348-55. Epub 2011 Mar 1.
The role of the organizational champion in achieving health system change.

Quality Improvement Collaboratives - New Paper

There's a new paper out (see below) which comes to a conclusion similar to ones found a few years ago - namely, in Quality Improvement Collaboratives, teams where the members have low knowledge of the topic or improvement science, are the ones which come out best. It also demonstrates that good leadership trumps the teaching of theory.

I've always thought that the more we push theory under the guise of "Improvement Science" at these short term interventions, the more we may confuse participants and in fact create a type of "performance anxiety" where they become afraid of doing what comes naturally, because it has been turned into what appears to them as a right-wrong application.

Implement Sci. 2012 Jan 9;7(1):1. [Epub ahead of print]
Factors associated with the impact of quality improvement collaboratives in mental healthcare: an exploratory study.
Versteeg MH, Laurant MG, Franx GC, Jacobs AJ, Wensing MJ.

ABSTRACT:
BACKGROUND:
Quality improvement collaboratives (QICs) bring together groups of healthcare professionals to work in a structured manner to improve the quality of healthcare delivery within particular domains. We explored which characteristics of the composition, participation, functioning and organization of these collaboratives related to changes in the healthcare for patients with anxiety disorders, dual diagnosis, or schizophrenia.

METHODS:
We studied three QICs involving 29 quality improvement (QI) teams representing a number of mental healthcare organizations in the Netherlands. The aims of the three QICs were the implementation of multidisciplinary practice guidelines in the domains of anxiety disorders, dual diagnosis, and schizophrenia, respectively. We used eight performance indicators to assess the impact of the QI teams on self-reported patient outcomes and a number of process of care outcomes for 1.346 patients. The QI team members completed a questionnaire on the characteristics of the composition, participation in a national program, functioning and organizational context for their teams. It was expected that an association would be found between these team characteristics and the quality of care for patients with anxiety disorders, dual diagnosis, and schizophrenia.

RESULTS:
No consistent patterns of association emerged. Theory-based factors did not perform better than practice-based factors. However, QI teams that received support from their management and both active and inspirational team leadership showed better results. Rather surprisingly, a lower average level of education among the team members was associated with better results although less consistently than the management and leadership characteristics. Team views with regard to the QI goals of the team and attitudes towards multidisciplinary practice guidelines did not correlate with team success.

CONCLUSIONS:
No general conclusions about the impact of the characteristics of QI teams on the quality of healthcare can be drawn, but support of the management and active, inspirational team leadership appear to be important. Not only patient outcomes but also the performance indicators of monitoring and screening/assessment showed improvement in many but not all of the QI teams with such characteristics. More studies are needed to identify factors associated with the impact of multidisciplinary practice guidelines in mental healthcare.

6 different types of change by scale - 2: Changing Minds

Large Scale Change means different things to different people. In his book, Gardner suggests six different types of scale. I found these different levels useful in thinking through the strategies I might use to effect proposed changes.

1. Large scale changes involving diverse populations on a national or regional basis
2. Large scale change involving an homogeneous group (e.g. peer group such as theatre nurses)
3. Changes brought about by technology, science or art (e.g. a whole generation has been influenced by Harry Potter)
4. Changes within formal settings (I think of bounded organisations here).
5. Small gatherings and the more intimate shifts in perspective (e.g. group of friends who decide to change their exercise habits and support each each)
6. Changing one's own mind (which, of course, we never admit is probably the most difficult!)

Seven Key Factors in how minds change - 1: Changing Minds

Notes from the book "Changing Minds" by Howard Gardner (2004)

What I learnt was that if we want to help someone change their mind about what constitutes good practice (and thereby figure their practice is not the best so they need to decide to adopt a better practice), then it helps if we can:

1. Demonstrate what has to be changed in a way that someone can figure out for themselves what the reason is for them to change. Some people do this analytically and others deduce or infer from what they learn that a change is necessary. I think it's important to understand it's the adopter who needs to reason, not the person pushing the change.
2. Research, evidence, statistical analysis etc is crucial when working with healthcare professionals for whom this is the base of their practice. The onus of evidence is on the person pushing the change.
3. The proposed change needs to connect at the emotional and intuitive level with the potential adopter. The really good proponents of change can combine the emotive, rational and evidence content in their rhetoric.
4. The concept of redesciption intrigued me. I can see now that the person who can describe the proposed change in many different ways, whilst remaining true to the core concepts and values, is more likely to be able to convince others to change.  Not least, being able to redescribe means you know your stuff and this enhances the credibility of the proposal.
5. Rewards are obvious - pay someone and they are more likely to do it. But this doesn't always lead to the mind changing. The most basic reward is praise and confirmation of the new behaviour.
6. Real World Events - means tagging your proposals to outside influences. As a friend pointed out to me recently, a great time to raise the profile of pancreatic cancer would have been in the days after Steve Jobs died. To make the most fo these (not always sad) events, is to be prepared.
7. Resistance... it takes two to create resistance. The best way I know to deal with it is to stop pushing and to see things form the other's perspective - then, find a way to break through the debate.