Laying the Groundwork: Developing an Agenda for Change

You have started as the head of a clinical group. During the selection process, you articulated several important changes, both short- and long-term, needed for the group. However, you realize many of the members in the team see different priorities. How do you bring everyone onto the same page?

To be a transformational leader, an agenda for change must be developed. A critical early step is to develop a guiding coalition (e.g. a committee, or group of leaders) who will help achieve the change. However, change actually comes from the efforts of many individuals. Your ability to affect change depends entirely on your ability to influence changes in behaviour.

Transformational leaders not only have an ambitious agenda for change, but also have explicit and multiple strategies to support and effect change ( more on the subject of Change Management). A common leadership mantra is to “lead by consensus”. This phrase is often misinterpreted to mean that leading by consensus means making decision by taking votes. However, leading by consensus means achieving consensus through influence and/or using processes that achieve consensus and alignment on goals. Consensus, as discussed in subsequent posts, requires multiple strategies such as providing broad input in to developing and refining the agenda for change, allowing candid and respectful conversation, providing transparency in decision-making, addressing resistance to change individually and collectively, responding to criticisms or concerns, and aligning decisions with the mission and values of the organisation. Gaining broad input requires multiple communication strategies such as person-to-person individual meetings with key individuals, town halls, and/or retreats (look out for more advice on establishing Vision/Mission in a future post). While obtaining broad input into decisions, listening to comments and incorporating feedback as much as possible is vital, leaders must also keep their eye on the ultimate goal.

As noted in my first post, the process and communication of decisions is critical to establishing your leadership style. A transparent and explicit process for decision making is essential, specifically how and by whom decisions are made. Individuals want to know the rules. If individuals feel the rules are fair and applied fairly, it is likely that most will comply. As part of effecting change, communicate the process to be followed for change at each stage and communicate the next steps in the process as it unfolds. Important components of transparent decision making are explaining which decisions are open to debate (the majority) and which are not; are decisions made by committee or an individual; and what decisions are made by general consensus or made by voting (as noted above, seldom is decision making by votes the best route to achieving leadership goals).

Another issue is to decide who is responsible and accountable for the change. As change occurs (and particularly in tight fiscal times), clinicians have traditionally become the guardians of the patients’ welfare, while management has become guardians of the budget. This dichotomy often leads to acrimony and even worse, poor decisions for the patient, the budget, or both. An alternative approach is to develop the understanding that responsibility and accountability is to be shared by both clinical and management leaders. While this is somewhat complicated from a reporting relationship point of view, it is much more likely to result in better decisions. To make this a reality, however, explicit steps are required. For example, cascade this principle of shared responsibility to all levels of leadership, make meetings multidisciplinary, provide broad communication to all constituencies, obtain broad input into decisions from all stakeholders, require joint meetings among and between leaders of different disciplines, and assign shared accountability for clinical and fiscal outcomes (I talk more about Accountability in a separate post).

“You can’t manage what you can’t measure”. This often-repeated statement is controversial because some say you can’t measure everything that is important. This may be accurate, but it is certainly true that you can’t measure everything that is important, easily. However, if something is immeasurable, you probably will find you cannot be confident that you have managed it. To be explicit about goals and assess success against those goals, you almost always need a measure. Thus, an early step in managing change is to determine measures of success.

Developing measures to evaluate success has three steps. First, the measure(s) must be cogent. There is no point measuring success against an easily measured, but unimportant goal. Second you need to ensure the measure is accurate. The initial response to unflattering data by clinicians is always to assume that the data is inaccurate. At first blush, clinicians are usually right. Therefore, before you take any action based on a measure, keep working on the measure until everyone agrees that it is accurate. Finally, the measure needs to be provided in a format that is easily understood. Measures are usually best depicted graphically, with (for example) monthly and 6-month running averages with targets highlighted in contrasting colours. Trending over time (with or without benchmarks) is also helpful to evaluate success.

Once cogent and accurate measures are available, goals should be assigned to individuals or groups that have the collective opportunity to improve. Don’t expect groups or individuals to improve on measures over which they have no control. Sharing group data with the large group is often helpful. However, in general, don’t single out individuals for criticism (see my post on Performance Management for more details). Individual performance needs to be evaluated but in general addressing poor individual performance should be managed individually.

In summary, developing an agenda for change requires many strategies, including achieving consensus and developing cogent, accurate and clearly presented measures.

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