Quandary-Mat: The retreating executives

If we have met, or if you have read other posts here, you know what I’m about: I help people help other people move ahead to get better. When I’m teaching and talking with leaders of change in complex systems, I get lots of questions about how to make other people join us in improvement work, as a staff team member or as a manager or senior executive.  

The challenges I hear from people around the country are consistent. So I’m starting an occasional series of articles, using the classic advice column format, to cover some of these greatest-hits challenges of complex change work. I will call it …

Quandary-Mat! Clean answers for the dirty work of leading change in a complex work world

First messy problem, here we go: The Case of the Retreating Executives

Dear Hunter,

I have been working on a project to redesign our primary care visits for better care for patients with both behavioral health and physical health needs. It’s been a challenging project, to say the least, but we are a good team and are proud of what we have achieved for our patients in this pilot project.

When the project started, we had full commitment and approval from our board of directors and executives to do this work. Now, as the project is coming to an end, we have a good program. We need to move from the pilot phase to a real implementation of the successful parts of our work. But now our COO and CEO are balking. How can I get them to follow through on their commitment? The team is feeling discouraged after all the hard work. And I feel misled and like a lot of energy and lessons are going to go to waste. Why did we bother?

Signed: Misled

Dear Misled,

First, congratulations to you and your team. You worked hard, took risks, tried new things, and figured out some answers for how to make care better for the people you serve.

Why did you bother? You bothered because this is important work and it needed to be tackled and figured out. Sounds like you won this project, at least to the point of spreading to the rest of the organization. Feel good!

Now, you are indeed thwarted. You are sure that the organization will benefit from the spread of key changes from your team to the larger organization. And it seems like the CEO and COO are backing away from their “commitment and approval.”

There are many reasons why senior executives may not be ready or willing to make changes recommended by improvement teams. Some easier to fix than others. And you have lots of options based on the situation. Above all, take it easy on yourself. Try to be curious instead of frustrated. Be persistent but don’t wear yourself out. Here are some questions, suggestions and reminders to help you plan your next move.

1)   What does/did commitment and approval mean to these senior leaders? At the outset of your improvement work, did they understand that your team would present them with effective changes for consideration for wide implementation? Or did they hear your request for commitment and approval as simply asking permission to do a finite project that’s over when it’s over? If they thought you just needed permission, start with some respectful educating-up about improvement. They may need to hear you talk about the big-picture of improvement: Test small in a project team. Test widely the specific changes developed by that team. Standardize what works across all teams or individual staff.

2)   Can you prove these changes are worth it? If you aren’t seeing measurable improvement as a result of these changes, either in performance measures for your pilot population of patients or in qualitative data like patient feedback and staff experience, you aren’t ready to spread your practice changes. If you don’t have the data yet, wait till you know your changes work for what you want to improve at a population level. If you have the data, make sure you share it and explain it as part of your case for change.

3)   Get clear on what you are spreading. Is it case conferences for complex patients, health coaching phone visits, or tobacco use screening and referrals? Be specific about the Who, What, How, the detailed activities and process steps you want others to adopt. Do you recommend a specific sequence of implementation of the list of new activities? Commitment and Clarity are what you need, from leadership and from frontline staff who would be making these changes. A set of specific changes also allows C-level people to to attach costs in staff time and other resources to each, and to learn what you know about the relative impacts of each. You want all the great changes to be implemented, but you should consider them individually or as smaller sets of changes. (Shout out to the great Sarah Fraser for making this clear to me years ago.)

4)   Further testing of your team’s solutions may be needed. Your pilot team learned what works better, by using small experiments, and feedback from patients/clients, and from your performance measures’ data. Fantastic. Other staff and managers may need the same opportunity. Answer their questions and concerns (including, perhaps, “This is too much extra work.”  … “We haven’t been trained on this”) by helping them test out your best ideas. Another benefit to wider testing: You may find reason to revise your plans for these changes when they move to full scale in the larger workforce.

5)   Put yourself in the CEO and COO’s shoes. Do the homework to make your case: costs, workflow changes, spillover effects and opportunity costs, staff training. Help the C-suite out. Ask them what questions they have about up-front costs, long-term costs and potential savings, potential for improved outcomes for patients, impact on pay-for-performance measures, and so on. Perhaps there’s someone on your improvement team who would love to help you geek out on budget and staff time implications of key changes, and get some recognition from the big bosses?

6)   If all else fails, figure out what you can sustain without senior leader help. This is tricky, because new habits that are not spread beyond the project team are difficult to sustain, but there may be process changes that can be maintained, or even spread to other teams, that are simple enough that you can get permission and don’t need any more resources from leaders.

7)   Within your project team, communicate carefully what is and isn’t spreading. It’s tough in the middle, between front-line staff who have been working hard and want to see their work impact the whole clinic, and senior leaders who have lots of competing priorities and opportunities. You can’t let down your team, but you can’t complain about senior leaders to the team either. Knowing why certain things were and were not picked up for spread will give you the explanations you need to represent the executives’ perspective to your team. Steer clear of “us versus them.”

8)   In the future, pick improvement projects carefully. Align with what the C-suite cares about. And make sure you agree on what the words “commitment and approval” mean.