You cannot look anywhere in health care today without confronting the need for major organizational change. It might be transforming roles and processes to improve patient safety and customer service. It might be creating new models of integration to improve quality while reducing cost — medical homes, accountable care organizations or bundled payments. Or it might be engaging communities in new ways to reduce health disparities, improve access or promote healthier lifestyles.
The track record of health care leaders in directing change is not good. Many change initiatives stall, while others leave a wake of discord and resentment. Even Lean projects — the current favorite among improvement methodologies — have a 30 to 50 percent failure rate. The problem is too widespread to be a matter of individual leadership performance; there is something more systemic at work here.
Using an Outdated Model
We believe that a big piece of the problem is the widespread use of an outdated mental model to guide change. This model, based on Frederick Taylor's 100-year-old theory of scientific management, invites us to look at an organization as a machine. It puts leaders in the role of engineers, responsible for designing and operating the machine to produce flawless execution. And it puts staff in the role of machine parts, performing their assigned tasks to the engineer's specifications, precisely and without variation.
The machine model has at least three major problems as a framework for leading change. First, it results in top-down decision-making that fails to harness the wisdom of front-line workers, who have the most intimate understanding of both patients and work processes. Second, it fails to engage the hearts of workers, who are less committed to work that is designed for them than to work they have helped design.
Third, it creates unrealistic expectations of control. Unforeseen events and unintended consequences imply culpability: Either the leader's plan wasn't good enough or the workers did not execute it properly. The resulting anxiety, defensiveness and self-justification divert considerable attention and activity away from the work at hand. It also makes people reluctant to talk about error and waste, which impedes process improvement.
Fortunately, a host of exciting and effective new approaches to organizational change are emerging from complexity science, positive psychology and relationship-centered care. We have integrated a number of these approaches into a model we call relationship-centered administration. It is an evidence-based alternative to the machine model and is far more effective.
Complexity theory provides a dynamic perspective on organizations, showing that an organization is composed of patterns of meaning (mission, purpose, knowledge about how to do the work) and patterns of relating (organizational culture) that are being created anew in each moment. These patterns usually perpetuate themselves over time but, sometimes, small disruptions or disturbances can spread rapidly to become transformative new patterns. This perspective refocuses change efforts from grand, elaborately detailed, top-down initiatives to smaller grassroots interventions with the potential to amplify and cascade. It also encourages reflection: noticing the patterns we are creating in each moment (often unwittingly) and enabling us to act with greater mindfulness and intention.
Several approaches from positive psychology offer useful perspectives on leading change: Appreciative inquiry is a well-established method that turns problem solving upside-down. Instead of looking for causes of problems, appreciative inquiry looks for the causes of successes. It presumes and calls forth competence rather than deficiencies. And because it involves sharing and comparing stories, it also helps build community. Positive deviance features an internally facilitated search for innovative solutions and best practices within the organization and constant rapid-cycle experimentation.
Relationship-centered care is a clinical philosophy that promotes partnership, shared decision-making and respect at every level of health care: among patients, family members and clinicians; among members of the health care team; and between health care organizations and their communities. Relationship-centered administration brings the same qualities of partnership and respect from clinical work into organizational behavior, treating clinical staff members the same way we want them to treat their patients.
Underlying and supporting these levels of partnership is one's relationship with self. Relationship-centered administration holds that self-awareness, self-acceptance, and awareness and acceptance of others are the foundation of effective leadership. These core capacities enable leaders to participate mindfully in the pattern-making of each moment, to call forth the best capacities of others and to form trustworthy relationships.
The New Model in Action
To bring these abstract principles to life, let's look at a real-life case study, Clarian West Medical Center in Avon, Ind. Former CEO Al Gatmaitan and his executive team determined that relationship-centered care would be one of the three pillars of the hospital, informing the creation and maintenance of a healing workplace culture that promotes caring; the well-being of patients and staff; and respectful relationships among patients, family, staff and the broader community.
Had they been working from a machine model, Gatmaitan and his team might have set up mandatory training in relationship skills for everyone in the hospital — in effect, programming the behavior of all the machine parts. Such approaches transmit an unspoken message of disrespect: that senior leaders believe staff members lack these skills and need remedial education. Instead, working from a model of relationship-centered administration, the leaders pursued a more emergent, mindful and affirmative approach.
They designed new hiring practices to attract and identify people with a strong relational orientation. They invited applicants to tell stories about their best moments in health care, and then listened carefully to assess their interpersonal awareness and capacity for self-reflection. The stories yielded data to assess each applicant's fit with the culture of relationship-centered care, and it attuned applicants to the values and specific behaviors that would be expected of them.
The senior leaders also developed a regular discipline of reflecting together on their behavior to better understand their contribution to the organizational culture. They thought through the relational implications of major business decisions; and they redesigned common organizational processes, such as budgeting and strategic planning, to foster greater participation and engagement (partnership) in the organization. They also coached and mentored their directors and managers to help them develop similar relational management practices.
Without a grand plan, but with a clearly articulated vision and a reflective approach to their day-to-day activities, the leaders succeeded in spreading the culture of relationship-centered care throughout the organization, resulting in not only high patient and staff satisfaction, but also high scores on quality measures and a strong financial performance.
This case study offers a glimpse of relationship-centered administration in action, showing an emergent, affirmative and participative change process that began with personal reflection and mindful behavior on the part of senior leaders. It's readily apparent how different it is from the traditional machine model and how it opens new avenues for bringing about change.
Anthony Suchman, M.D., M.A., is a senior consultant and the director of the Healthcare Consultancy at the McArdle Ramerman Center in Rochester, N.Y. David Sluyter, Ed.D., is a retired senior advisor with the Fetzer Institute in Kalamazoo, Mich. Penelope Williamson, Sc.D., is a senior consultant with Relationship Centered Health Care and an associate professor of medicine at the Johns Hopkins University School of Medicine in Baltimore.
This article is adapted, with permission, from the authors' new book, Leading Change in Healthcare: Transforming Organizations Using Complexity, Positive Psychology and Relationship-Centered Care (Radcliffe Publishing, 2011, ISBN 978-1-84619-448-1). The book publisher reserves all rights in copyright to the contents of Leading Change in Healthcare ("The Work"), and permission granted for this adaptation in no way transfers, assigns, or grants any other right in copyright related to The Work.