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CHAPTER 1

Future of Evidence, Innovation, and Leadership in Health Care: A Model for Leading Change

Daniel Weberg and Sandra Davidson

“The dogmas of the quiet past, are inadequate to the stormy present . . .”

CHAPTER OBJECTIVES

Upon completion of this chapter, the reader will be able to:

Describe key leadership elements for building innovative organizations in health care.

Synthesize core aspects of evidence and innovation in relation to the changing healthcare system.

Discuss a new framework for innovation in health care.

Now more than ever, the need for innovation in health care is clear. A shift from volume to value has disrupted the status quo and demonstrated that the models of the past are no longer relevant or sustainable ways to improve the quality, cost, affordability, and experience for the greater population. Healthcare organizations are struggling to combine, align, merge, adapt, reinvent, and even innovate new ways to provide superior quality while reducing the cost to the consumer and the overall system.

Are We Moving Too Slowly?

Many healthcare start-up entrepreneurs think so! In recent years, venture funding to healthcare-focused start-up companies was the highest in history (Gandhi & Wang, 2015). Innovators, many with little formal healthcare experience, are developing software, devices, systems, and solutions to fill the gaps left by the shifting healthcare system or to capitalize on emerging opportunities. Universities, venture capital firms, and large organizations are creating incubators for healthcare start-up companies to spin out solutions focused on digital health, pharmaceuticals, medical devices, and diagnostics.

Consumers are also demanding and purchasing services outside the traditional medical model. MeMD, Teladoc, and HealthTap are technology companies that decentralize care and allow patients to see a clinician from their computer or mobile device in seconds for a low one-time charge. Robots are enabling specialists around the world to examine, operate, and follow up with patients with solutions from InTouch Health and other companies. Sensor devices are allowing healthcare professionals to amass petabytes of data on patients that could not have been collected previously. These petabytes are expanding the sources of data that can be analyzed and translated into evidence automatically and instantly. There is so much data produced on a continuous basis that practitioners can easily access that we do not know what to do with it all. Traditional health professions education has not yet caught up with the available technology or mounds of data. Healthcare providers today have not been taught how to assess, diagnose, treat, and monitor patients based on this data captured millions of times per second. The episodic basis of care-related data (vital signs, activity, diet, medication absorption, etc.) is quickly becoming irrelevant. Technology is challenging old models of care, enabling new ones, and providing the evidence of what works and what does not work.

It seems obvious that the needs of clinicians, healthcare consumers, and populations are rapidly changing due to technology, health policy changes, and innovations. Equally as important is the changing focus and scope of leaders in the healthcare industry. The call for outside-the-box thinking, leading, and organizing is loud and clear. However, there are few frameworks of leadership, innovation, and evidence that help new and experienced leaders understand the complexities of the new world of health care. This text has provided the content and evidence needed to inform a new framework, and this chapter will present a synthesis and starting point on which we might build and refine such a framework. We argue that by thinking more intentionally about the interdependence and connectedness of leadership, innovation, and evidence, and by utilizing the skills, attitudes, and ideas presented in this text, leaders in health care can create a greater impact on the outcomes across the system. Without a paradigm revolution, entire organizations, professions, and systems may fail and disappear.

Are We Moving Too Slowly?

Evidence

Evidence has evolved over time to create rigor, validity, and a rational hierarchy for assessing and appraising research and turning it into insights to improve care outcomes (Melnyk, Gallagher-Ford, & Fineout-Overholt, 2016). This evolution serves as an excellent and needed foundation on which practitioners can build and incorporate new data into the system and turn it into evidence. Current evidence-based practice hierarchies limit sources of valid evidence to systematic reviews, randomized control trials, and so forth. However, by viewing evidence as generated only from the few sources within the box, we fail to integrate the new emerging sources and insights of evidence, like technology and powerful analytics.

Emerging sources of data that are disrupting existing evidence frameworks include big data technologies, wearable monitors, analytics, continuous patient monitoring, and electronic medical records (EMRs) (FIGURE 1-2). These outside-the-box disruptions are signposts for leaders and practitioners to innovate new possibilities for the evidence hierarchy and dynamic. In addition to the technologic possibilities for generating and aggregating evidence, we must also consider the relational and contextual aspects of evidence-based practice. How do we engage patients, communities, and providers in collaborative decision making about the evidence?

FIGURE 1-2 Evidence beyond the box.

Description

Leaders in health care must be able to identify disruptions, challenge current thinking, and begin to facilitate the integration of these new sources of evidence into new ways of clinical decision making.

As leaders read the signposts, gather learnings, and test ideas, they will begin to break down the rigid walls of the status quo that organizations build. By connecting evidence to innovation and leadership, a new paradigm of evidence begins to emerge that is fluid, permeable, and able to incorporate out-of-the-box thinking to inform proven methods—in essence, getting rid of the box altogether and creating a more networked and complex approach to linking, trying, and implementing evidence-based practice (FIGURE 1-3). In a networked complex system, the practices informed by evidence begin to connect and incorporate newer sources and insights, thus strengthening the practice and evolving our thinking. This allows us to stay relevant and nimble in how we respond to shifting information and needs. Some practices, such as big data analytics, may have stronger ties to the new sources, such as continuous monitoring. Thus, the fluidity of the new evidence bubble allows practices to shift based on continuous assessment and learnings from innovative testing of linkages among the elements. For example, the ubiquitous adoption of EMRs may signal a need to link the evidence hierarchy to EMR insights and data sources to build new practices, but the use of continuous monitoring may still be in the early stages and have fewer linkages that inform new care practices.

FIGURE 1-3 Emerging sources that further inform evidence-based practice.

Description

It is important to also note that evidence is not a silo. The discussion of evidence presented here is intended to help leaders conceptualize one part of the larger framework discussed throughout this chapter. Accepting new forms of evidence informs expansion and connection building, and it helps us anticipate the future directions of care. It allows us to begin to recognize new patterns. Evidence provides the foundations of innovation and leadership, and innovation and leadership are required to build more evidence. It is an iterative and dynamic system with complex linkages. It is essential that leaders have competence in linking a body of evidence to their innovation facilitation and stop thinking innovation results from an “aha” moment or from spending a day putting sticky notes on a wall. Innovation arises when the participants in the innovation work are informed in the body of evidence and build upon it rather than disregard it.

Innovation

From a traditional perspective, innovation as a whole is considered outside the box, but from the perspective of an innovator, there are always radical ideas that continue to inform practice and aid in the evolution of new ways of thinking. New and radical technological disruptions are often considered innovation, but other practices, such as process redesign, failure, and patient-generated innovations, are not. Even innovation has a cutting edge that continually challenges and moves the practice of innovation forward (FIGURE 1-4).

FIGURE 1-4 Innovation as its own box?

Description

Disruptive practices that are changing how innovation is practiced include conceptualizing failure as necessary, incorporating and relying on patient-generated innovations, the use of social labs, and building innovation from a foundation of evidence-based practice. These trends in innovation practice rely on the connections among multiple parts of the organization and cannot be accomplished in isolation. Innovation requires a network of people who can collaborate, envision the future, overcome barriers, and generate a new vision and direction for the healthcare system to evolve.

The practice of innovation (in health care particularly) is maturing from the notion of idea generation and radical product creation to a practice that fundamentally derives value and content from the front lines of the organization. Healthcare leaders should be competent in innovation practice, accept failure as part of the journey, and develop their own competencies to support innovators in their organizations by building partnerships across silos and teams. Leaders must continually evolve the innovation practice, looking for new sources of ideas, implementation techniques, and ways to keep change relevant to the organization. Therefore, the innovation practice should continually test and trial new processes of change. Evidence-based innovation will require more leadership energy because many people conceptualize it as a separate process. Innovation is often viewed as new, exciting, and future oriented, and evidence-based practice is perceived as steadfast, slow, and present focused. Yet if you combine the two practices in new ways, such as using evidence as the foundation from which to inform innovation (new practices and processes), they actually inform each other and synergize the system change. Gone are the days in which we show up unprepared and uninformed to brainstorming sessions. Instead, we should be intimately aware of the evidence around the problem we are trying to solve and make an informed decision to innovate and/or improve. It is also important to know that innovation is not always the process that is needed. Leaders should be adept in assessing the need for innovation or the need for improvement.

The concept of failure can provide a similar example. If failure is viewed through the traditional lens, in which it is punitive, negative, and avoided at all costs, it actually limits the ability of organizations to innovate. By combining the notion of failure and linking it to evidence (knowing what does not work), there emerges another source of innovation rather than a roadblock to it. The failure of practice, process, trials, change, and tests provide a rich source of evidence that can be used as a foundation to improve innovation in the future. Failure should be celebrated for providing insight into all the ways things do not work and providing clues to what is not yet possible. The role of the leader is to document, revisit, and incorporate failures into the conversation regularly in order to ensure movement forward. Failure becomes a body of evidence that can inform future innovation and improvement efforts. It should not be kept secret. Leaders should strive to fail early and often to rapidly move innovation forward because failure is the process from which the new replaces the old.

Innovation is the force that propels evidence creation and provides a practice for leaders to use to evolve the organization, and it infuses energy into the system to catalyze change. Innovation is not a separate team or event but rather the life force that keeps individuals, teams, and organizations relevant (FIGURE 1-5). Innovation occurs all the time, at various impact levels, and informs how evidence is created and leadership is practiced. If innovation is absent, so is the ability for the organization to grow, learn, and adapt. Building a competency in basic innovation concepts and practices is a prerequisite for leaders, regardless of your role in the organization or system.

FIGURE 1-5 The edge of innovation: New sources and practices.

Description

Leadership

It is possible that the notion of leadership carries with it the most history, misconception, and biggest lack of evidence of all the elements in the innovation, evidence, and leadership framework (FIGURE 1-6). Twentieth-century leadership practices built on the ideas of individualistic power dynamics, followership, command and control, and hierarchy still dominate organizations in health care. Popular media books suggest hundreds of simplistic and overgeneralized tips that leaders should follow to become great but minimize or are completely devoid of research on effective leadership. The disruption of the tradition of leadership thinking and practices is a challenging endeavor that will require evidence, innovation, and significant energy. However, it is an essential element to transform health care. Throughout this text the argument has been made, and supported by evidence, that leadership needs to move toward a distributed, networked, team-based, and relational approach that is supported with the latest evidence and fueled by innovation.

FIGURE 1-6 Traditional in-the-box leadership.

Description

Leadership relies on partnerships, and partnerships are built through networks. To build a network, and thus a partnership, leaders should focus on relationships among colleagues and teams (Porter-O’Grady & Malloch, 2014). The stronger the leader’s network, the better the chance that diverse thought and sources of evidence will emerge to inform innovation and change (Weberg, 2013; White, Pillay, & Huang (2016). As the network strengthens, the distribution of decision making can be improved as well. Placing problem-solving and decision-making power at the point closest to the problem allows those with the best connections to relevant evidence to create and sustain solutions (Porter-O’Grady & Malloch, 2014). Distributed leadership requires partnership and team-based models of collaboration to leverage the diverse skill sets of organizations. Partnerships and teams allow groups to leverage their collective expertise and evidence to cocreate innovative changes and move the organization forward.

The most important shift in our understanding of leadership is that it is a set of behaviors that helps the organization focus and align time, resources, and energy through relationships and networks. It is not about controlling but rather facilitating, connecting, and emancipating. Leaders may accomplish this by building relationship-centered cultures and translating information in ways that are meaningful and relevant in local contexts. In essence, leaders can help create the organizational norms that value shared decision making, innovation, and evidence integration. These norms will give rise to a culture that supports evidence-based innovation.

Depending on the current practices of the organization, leaders will need to test and try new leadership behaviors in different patterns and ways. For example, if the organization has a strong relational and network culture, the leader may be able to more easily try different practices in distributed leadership. If the organization is steeped in hierarchy, the practice of building evidence-based leadership behaviors may be a good use of energy. There is no plug-and-play methodology to change culture and leadership practice other than to innovate, fail, and support decision making with the best data and evidence available. This is the challenge of 21st-century leadership. Unlike leadership models of the past that rely on neatly listed steps or recipes for change, transformational and relational leadership embraces the messiness rather than seeking to control and confine it. FIGURE 1-7 represents how leadership might look as more collaborative and networked approaches are incorporated. These new approaches will become the new norm, replacing antiquated practices like command and control tactics. The more networked, distributed, and team-based leadership becomes, the more capacity that is created for evidence-based innovation. As the leadership practice matures, the capacity to incorporate more innovative practices will increase.

FIGURE 1-7 Leadership beyond silos and hierarchy.

Description

This is the challenge of 21st-century leadership. Unlike leadership models of the past that rely on neatly listed steps or recipes for change, transformational and relational leadership embraces the messiness rather than seeking to control and confine it.

LEARNING ACTIVITY

Reflect on your personal experience with in-the-box leadership and answer the following questions:

Have you been in a leadership role in which you were expected to take on the traditional leadership behaviors (e.g., command and control)?

Have you been in a staff position in which a hierarchal leadership structure existed? What was your experience of being led by a traditional leader?

How do you imagine your experiences would have been different with an innovative or transformational leadership practice?

Compare your reflections and thoughts about leadership with a peer.

The Evidence–Innovation–Leadership Framework

The evidence–innovation–leadership framework proposed in this text is an interdependent dynamic that helps leaders frame behaviors, evidence, and change in a way to further organizational evolution in health care (FIGURE 1-8). Often, evidence, innovation, and leadership are seen as disconnected and different, yet this framework describes ways they are synergistic and interdependent. Each concept has been detailed with a description of how organizations have boxed in the notions and created silos around each practice. For example, evidence has been boxed by the rigid use of evidence hierarchy, innovation has been boxed by the expectation for radical change, and leadership has been boxed by the notion that total control is necessary. It is important for leaders to understand the roots and assumptions of these boxes to create new ways of working and integrating concepts that may be more effective.

FIGURE 1-8 The evidence–innovation–leadership framework.

Description

Building on the boxed assumptions, each concept of the framework has been described in a way that links it to the others and demonstrates their interdependence. This reconceptualization is meant to provide guidance for leaders to build upon and navigate within, to drive evidence-based practice, innovation efforts, and leadership development. Surrounding each of the concepts are the drivers presented throughout this text, including patient-centered care, technology, failure, pattern recognition, and partnerships that keep the framework fluid, informed, and relevant.

Patient-centered care provides relevancy to the framework by grounding it with the viewpoint that patient care is the focus of most healthcare change. Even business model innovations, evidence-based leadership, and technology changes should be done to improve the care experience, health, and safety for the end user of the system: the patient. Relationship-centered care is a framework for thinking about how we engage with patients, providers, and stakeholder communities in the service of patients. Without the perspective of the patient, there is a risk of focusing energy on evidence, innovation, and leadership efforts that are not aligned with the mission of the organization. Removing the patient-centered care driver from the framework changes the balance of the three core concepts of evidence, innovation, and leadership, and it begins to fragment the system. Patient-centered care and relationship-centered care is discussed in Chapter 12.

The technology driver helps accelerate the framework’s rate of change and the ability to gather, interpret, and act on data and evidence. Technology is a cultural norm and expectation that can move a process forward by simplifying complex data for interpretation or providing easy access to information to develop new practices. Technology can also speed up failure in a suboptimal system. Implementing technology on top of a broken process only serves to break the process faster. For example, providing clinicians with mobile devices that can access Google and other data sources without ensuring competency in understanding evidence validity and quality may lead to faster access to inaccurate information. Due to the integration of technology into our everyday lives, technology is quickly becoming the interface that drives care decisions and even patient-centered interactions. We can understand all of the various data points about a patient and at the same time instantly connect them with care team members. Leaders should have an understanding of the impact technology has and the speed at which it changes processes within the evidence–innovation–leadership framework. The technology driver is discussed in Chapters 10 and 11.

The failure driver provides the framework with continuous learning feedback loops and a safe environment to test new ways of work. Continuous learning emerges from tried and failed attempts at change, yet failure is continually avoided in healthcare organizations (Porter-O’Grady & Malloch, 2016). By acknowledging failure and diving deep into the insights that can be gleaned from less-than-successful attempts at change or practice, we can avoid making the same mistakes repeatedly. Moreover, we get better at failure, and this means we are able to learn more quickly. Celebrating failure can build learning that then cycles back into the organizational knowledge base and continues the iteration and movement forward to novel solutions. Failure is essential in evidence generation (building on research, learning what does not work), innovation work (quickly iterating to create novel solutions), and leadership (understanding the networks and increasing the span of impact). Without the failure driver, leaders condemn organizations to avoid or ignore failure at their own peril, which limits the creation of innovation and the use of novel evidence. Acceptance (even celebration) of failures requires leaders and organization-wide cultures to transcend ego, blame, and punishment to gain insights and grow stronger. The failure driver is discussed in Chapters 3, 6, and 8.

The pattern driver provides a different lens through which to conceptualize evidence, innovation learnings, and leadership signposts. In complex systems, individuals, teams, organizations, and technologies interact in a multitude of ways to accomplish tasks, work, and achieve outcomes (Uhl-Bien & Marion, 2008). The complexity of the system is so high that the impact of individual actions and interactions are nearly impossible to predict by any one leader. Therefore, leaders should look for emergent patterns in the organization to better understand how evidence, innovation, and leadership actions are changing the system. For example, a care practice based on one expert’s opinion would be haphazard compared to looking across multiple sources of evidence, such as systematic reviews, patient preferences, and local best practices, for patterns that support a practice change. In innovation, patterns in technological change, consumer needs, and clinician practices provide the context on which to build novel solutions that add value. Patterns in failure also provide evidence that leaders can use to focus innovation efforts, understand what does not work, and search for more evidence to build stronger solutions. Without pattern recognition as a driver in the evidence framework, innovation and leadership become linear endeavors that rely on predictable processes rather than embracing the inherent complexity of relationships and systems. Linear leadership, prescriptive solutions, and a cookbook approach to evidence implementation may result in simpler solutions that lack relevancy and impact in complex environments. Patterns provide the signposts by which leaders can frame evidence and innovation within complex relational systems. The pattern driver is discussed in Chapters 3, 4, and 13.

The partnership driver provides the energy to create and strengthen connections and relationships among the core concepts. A core belief within this framework is the impact that groups of people, teams, and organizations can have in changing a large system. The partnership dynamic provides the tools, energy, and linkages to strengthen these networks and better link evidence to innovation and leadership practices. Without partnership as a driver, leadership can become an individual endeavor, innovation becomes slower and less relevant, and evidence that emerges tends to be less trustworthy or valid and reliable. Partnership improves diversity of thought, evidence sources, and leadership resources so that more diverse solutions are generated and more impactful outcomes can be achieved. One example of this is the use of unit-based teams. Facilitating local teams to source and implement evidence and innovation at the point of care results in greater fidelity and effectiveness of processes and solutions. The practice of engaging unit-based teams to solve problems instead of relying on individual leader solutions has provided sustainable and highly effective changes in some healthcare organizations. The partnership driver is discussed in Chapters 12, 13, and 15.

The evidence–innovation–leadership framework proposed here is focused by the lens of patient-centered care, accelerated by technology, fueled by failure, guided by patterns, and strengthened by partnerships. The framework provides a way for leaders to think about the interdependencies necessary to change the healthcare system and lead evidence-based innovation. The framework is a foundation and a call for a new healthcare system.

Using the Evidence–Innovation–Leadership Framework to Create Change

For an evidence–innovation–leadership framework to exist as a way of doing business and building new systems, certain organizational and role capacities must be established. Leaders in organizations will need to be intentional about the design, development, and focus to create the context that will ultimately support new ways of care, practice, and health care.

The following components must be incorporated in the design of this new system to create an environment in which evidence, innovation, and leadership intertwine and thrive (Malloch & Porter-O’Grady, 2010):

A commitment to data and information-driven decision making must be made at the very senior levels of the organization in a way that ensures the decisions will be generated in alignment with the evidentiary dynamic.

An investment must be made in the resources needed to build the data and information infrastructure. This includes the appropriation of sufficient hardware and software to ensure the utility and effectiveness of information-driven decision making and determination of fixed-process approaches to operational and clinical decision making.

Meaningful engagement must occur with point-of-service knowledge workers and patients at the outset of the design of management and clinical information infrastructure, software, and processes. This includes using an effectiveness evaluation as a way of ensuring a goodness of fit between the proposed data tools and the utility of their application.

A commitment must be made to ongoing professional development of managers and leaders in the concepts of complex adaptive and responsive systems, role agency, networks, and emergent leadership. Leaders at every level must develop the competencies necessary to ensure that innovation and creativity are embraced as the way of being in the organization.

Ongoing engagement must occur with health professions education programs to continually strengthen the practice–education connection. Leadership needs to support connection and integration at every level of the organization. This includes supporting individual practitioners and teams to participate in mentoring and teaching students align leadership activities at the highest levels.

Reconceptualize healthcare organizations and hospitals as complex systems composed of networked relationships. Multifocal interactions, interdependence, and relational processes become the organizing framework, replacing vertical decision models, operating silos, and nonaligned departmental configurations.

Eliminate discipline-specific locus of control in favor of interdisciplinary processes, teams, and collaborative decision making, resulting in an integrated model of evidence-driven decision making, practice, and impact evaluation. This includes the acknowledgment that sustainable outcome-oriented, evidence-driven practice represents the synthesis and coordination of the effort of all stakeholders, as opposed to focusing only on unilateral measures of incremental impact (isolated, nonaligned, discipline-specific outcomes).

Embrace and leverage the organization as conversation perspective to strengthen relationships, communication, alignment, and transparency across the organization.

Invest leaders’ time and energy into building quality relationships, resilience, and capacity in all three domains: innovation, evidence, and leadership.

Construct and develop a strategic plan and targets for transforming the system environment from a fixed operational model to a fluid, data-driven organizational framework supporting evidentiary systems, structures, processes, applications, and evaluation. This includes consonance among evidence-driven strategic trajectories, resource capitalization, management and operational reconfiguration for leading, and clinical facilities for execution.

These considerations provide starting points or levers that leaders can use to influence their teams, organizations, and broader networks to support movement toward a value-focused healthcare system. The application of these concepts and the evidence–innovation–leadership framework will require risk taking, adaptation, vision, opportunity, facilitation, information, and technology (Weberg, 2013). This means that at an individual level, the leader’s own capacity for apprehending these various aspects will determine his or her effectiveness and reach. There are specific competencies leaders can develop that will increase their capacity for changing the system.

Competency 1: Understand the Foundations of the Innovation, Evidence, and Leadership Dynamic

Leaders who wish to change the system must first have an understanding of the complexities and history that are driving current behaviors and the barriers and benefits that allow that behavior to continue (Porter-O’Grady & Malloch, 2016). Specifically, understanding the foundations of evidence, innovation, and leadership in the context of health care is very important.

The foundations of evidence consist of the evidence framework, critical evidence appraisal models, and evidence-based practice models. Understanding these core concepts and practices allows the leader to quickly and accurately gather evidence to inform decision making, leadership, and innovation. Evidence can inform the change in practices and the beginnings of innovation processes, and provide context for the healthcare system as a whole.

The foundations of innovation consist of innovation methodologies like design thinking, innovation frameworks that include failure as normative, and innovation leadership behaviors that support the practice. Understanding basic innovation methodologies allows the leader to view change as normative and develop behaviors that support teams in problem solving. An innovation mind-set also provides a lens for leaders to view new sources of evidence, test new ideas and practices, and develop new models of care to change the entire system. Innovation competence is often overlooked by organizations, but it is an essential skill in remaining relevant and driving improved outcomes in health care. Chapter 9 has a discussion of innovation and performance improvements processes with a focus on how leaders can incorporate both processes in order to create change.

The foundations of leadership are rooted in leadership theories such as trait, style, transformational, relational, and complexity. By understanding the sources of decision making, power, accountability, and the variety of lenses available through which leaders across the system may make sense of their work, the available solutions and directions become more generative rather than prescriptive. The evidence-based and innovative leader can then develop strategies to overcome resistance, build networks, and create teams that are wired for system change. Understanding that leadership is a complex set of interactions and information that is grounded in relationships, evidence, and innovation is key to building the future of health care.

Each of these foundations provides the starting point for research, learning, and the growth of leaders in health care. The beginnings of each of these concepts are presented in this text with specific examples and tools for change. Additionally, leaders should read seminal texts and articles and search for new evidence to continually build their knowledge and skill. The point is to not silo one’s competency in one discipline but to see the patterns and connections among all the disciplines of change. Additional topics that should be studied include culture, communication, health policy and law, business operations, and basic technical and informatics knowledge.

Competency 2: Leading Yourself

Leadership, especially in health care, requires significant energy, reflection, and networking. It can be easy for leaders to focus energy on others, the organization, or the work without regard to their own health and family. Leading yourself includes the concepts of creating your own context for action and balance. Energy management, nutrition, wellness, reflection, and renewal are concepts that professional athletes use for peak performance, and similar concepts can be translated to leadership peak performance. Leaders should make time to build energy through physical fitness and proper nutrition and snacking routines. Wellness and renewal activities, like vacations, deep breathing between meetings, and making time for friends and family, allow leaders to stay grounded in all aspects of their lives and maintain energy throughout the day. Additionally, leaders are visible role models to others in the organization. By modeling self-leadership and encouraging self-care in others, leaders can have a secondary positive effect on the health and resilience of the wider organization. Leaders can also build mental and emotional capacities through emotional intelligence work, mindfulness, and reflection. All these skills help you as an individual engage fully in leadership behaviors. It is necessary to build your own endurance and capacity to weather the stress of challenges that are an inevitable aspect of change and innovation. It is also important for leaders to recognize and intervene in their own burnout and toxicity. If self-care, team-care, and organizational values are not aligned there becomes a real risk for individual leaders to experience negative emotional, physical, and psychological impacts. Toxicity in teams and organizations is real and under-reported in systems. We discuss this in depth in Chapter 13.

DISCUSSION

What self-leadership practices do you currently engage in? What do you think are the biggest barriers to self-leadership? Are there self-leadership behaviors and practices that you want to start? How can you set yourself up for success? Are there peers and/or mentors that you could invite to join the journey toward self-care with you?

Competency 3: Building an Advanced Innovation Skill Set

After leaders have a good foundation in evidence, innovation, and leadership and have begun to reflect on their leadership journey, more advanced innovation competencies can be introduced. These include advances in design thinking, risk taking, strategic alignment, and culture-building skills that can further develop an ecosystem of innovation across departments, organizations, and systems. Concepts such as systems thinking, complexity leadership, and network interaction theory are examples of advanced innovation perspectives that leaders can use to shape change and create lasting innovation structures.

Innovation competency for leaders is not the ability to generate significant numbers of ideas but rather the ability for leaders to create safe conditions for risk taking and leverage resources to support teams to create novel ideas. Rather than the leader acting as an innovator (which may be the case at a basic competency level), this advanced innovation competency for leaders is about creating the conditions for innovation to happen through the actions of others. Leaders with advanced innovation skills can view complex systems as interconnected wholes and recognize emergent patterns that guide evidentiary and innovation dynamics. Complex adaptive and complex relational perspective taking can result in the creative emergence of new ideas and information. Leaders must be aware of the emerging edge of the healthcare industry and respond accordingly. The advanced innovation leader has multiple streams of information, learning, and insight that help inform decision making. These can be informal sources, such as friends, coworkers, and perspectives outside health care social media and popular culture; or they can be formal, such as journals, research, or organization-specific channels of knowledge dissemination like clinical practice guidelines, intranet resources, and special interest groups. Advanced leaders should have competency in developing and accessing both formal and informal networks.

Viewing the system in novel ways is important, but equally important is measuring the impact of innovation and evidence. Leaders of innovation need to understand and look for ways to assess, measure, and otherwise illuminate how new evidence and innovations are changing and influencing the system. This requires an understanding of metrics. For example, failed innovations may be unsuccessful from an individual project standpoint, but the ripples of failed projects or patterns of innovation activity can open new opportunities, break down previous barriers, or inform others to change efforts in the organization. These impacts are complex and at times difficult to see, but advanced innovation leaders can utilize their networks and pattern recognition to gather diverse sources of information and translate this information into meaningful measures of evidence and innovation.

Building relationships across networks requires leaders to create connections beyond the span of their everyday work and to develop the capability to communicate with diverse groups for information and knowledge sharing. Building your network occurs on two levels: informational and relational. First, the leader should create ways for information to be shared with their team members and with members of other teams. Connections enable sharing information through e-mails, conversation, technology, and interaction. For example, moving from data sharing at a physical location, like a whiteboard, and digitizing it into a secure web-based platform that allows for real-time viewing and manipulation of the information, and is accessible by multiple teams who may be working at a physical distance would be a connection for sharing information. The second level of building a network is to develop relationships. The leader’s relationships determine the quality, strength, and longevity of connections that are made. By building strong relationships, the leader increases the likelihood that the information exchanged between the teams will be of better quality, accuracy, and relevance. It also increases the likelihood that team members will develop relationships with counterparts of other teams. Mutual respect, trust, and valuing the expertise of others are foundations of relationship building. Creating connections, building relationships, and knowing how and when to mobilize them is a key advanced innovation skill.

Finally, advanced innovation leaders foster high-performing cultures, and this enables innovation. Cultures are the accumulation of behaviors and interactions that occur among people in an organization. Behaviors turn into norms, and these norms turn into subconscious (unspoken) rules that govern future behavior (Schein, 2004). Leaders have the ability to influence behavior by creating the conditions and structures that foster, for example, open communication and acknowledging and learning from mistakes.

The complex relational perspective is also useful in fostering high-performing cultures. Leaders can begin to transform patterns of meaning and patterns of relating in ways that will support and align with the innovation–evidence–leadership framework. Patterns of meaning within organizations can be influenced by paying attention to what people are talking about, what is rewarded, or what energy and resources are focused on. If leaders discern that patterns of meaning are not in alignment with the framework, they can begin to change the patterns of meaning by shifting the attention, rewards, and language in ways that are more generative and aligned with the importance and value of innovation and evidence. Patterns of relating are equally as powerful. Leaders should be aware of the reasons, issues, and events that people organize their interactions around. For instance, if there is a monthly full-day meeting that brings stakeholders together to discuss a certain topic (e.g., risk management), leaders should evaluate if that topic and the intended purpose of the meeting are time and energy well spent. If the organization wants to foster innovation and empower providers at the point of care to engage in tinkering and process improvement, a full-day meeting spent scrutinizing deviations from the status quo and consistency might be sending the wrong message. Leaders should seek to align patterns of meaning and relating with the organization’s highest aspirations and priorities (Suchman, 2011). TABLE 1-1 summarizes the requisite skills associated with advanced innovation competency.

TABLE 1-1 Advanced Innovation Competency

Skills

Complex adaptive systems view

■Pattern recognition

■View complex interrelationships among teams and systems

■Establish strong feedback loops with formal and informal sources

Measure system-level outcomes

■Recognize impacts of innovation and evidence across the system

■Determine appropriate metrics to understand impacts

Relationships across the network

■Span boundaries across organizations

■Influence the network

■Model effective network development

Create high-performing cultures

■Align energy and resources to match organizational goals

■Model and facilitate open communication

■Notice and leverage patterns of meaning and patterns of relating

Competency 4: Communicating and Connecting

Leaders who wish to transform systems must be masters at communicating and connecting across networks, teams, and organizations. Communication competencies include the ability to build relationships and networks, as discussed previously, and also the ability to communicate vision and information in a way that influences others to change. The term influences is intentional in this context. Leadership is the influencing of others to adapt and change in the face of complex and unpredictable situations (Weberg, 2013). To influence teams of people, leaders must be able to articulate rationale, evidence, data, meaning, and impact clearly, linking those elements to the broader mission of the team or organization. This act is different from motivation. Leaders are influencers more often than they are motivators.

Another important competency related to connecting and communicating is the notion of transparency. In organizations, information is interpreted, analyzed, and acted upon at each level. For example, uninformed rumors of an organizational change can lead people to quit preemptively, look for other opportunities, or launch negative campaigns before official announcements are made. Leaders who value transparency and can communicate effectively are able to anticipate or gain insight about these rumors and work with their teams to communicate and connect concepts in a more focused and meaningful way. For example, the leader may learn of the rumor from his or her professional network and hold a staff meeting to answer questions openly and honestly, providing information proactively. A noninnovative leader would shy away from such conflict and allow team energy to be spent on anxiety-generating activities, thus pushing productivity down and chaos up.

Relationship-centered care comes to bear in our discussion of communicating and connecting, which are an elemental aspect of effective relationships. Relationship-centered care is supported by what Suchman (2011) described as relationship-centered administration. In essence, if we as leaders want care providers to engage patients and families in respectful, honest, and deeply engaged relationships, we must communicate and connect with care providers and patients in ways that resonate with those very same qualities. It is the epitome of walking our talk. But communicating and connecting is not only about talking. Leaders must also be astute listeners. The skills of deep listening (empathically and emergently) are essential for fostering high-quality relationships that ensure connections (Scharmer, 2007). The concept of relationship-centered care is discussed in Chapter 12.

Communicating and connecting is a competency that innovation leaders must hone and continually demonstrate. Deep listening, influencing, transparency, and relationship building are critical to fostering a culture where evidence and innovation are valued and seen as resources for creating high-quality patient care experiences.

Competency 5: Building Momentum and Initiating Change

The fifth competency for healthcare leaders is the ability build momentum that results in system change. This requires a skillful synthesis of the previous four competencies. The important part of this competency is not the magnitude of change or innovativeness of the change but rather that the leader builds confidence and comfort in trying new things. This also extends to fostering self-efficacy for change and innovation among your team and the larger organization. From a complex relational perspective, even the largest of changes begins with a single step (so to speak). Often, there are also missteps and steps backward in this process toward change. Perseverance, learning from (celebrating) mistakes, and failing forward are all important elements of building momentum for change. Leaders who are new to this way of being may be frustrated because they expect that change needs to happen on a grand scale to be meaningful, or they might be anxious because change may not be a controlled process. The following are some points to ponder for leaders seeking to build momentum:

Any movement in the right direction is worthy of celebration. Celebrating small wins creates energy and visibility, which in turn creates momentum for change.

Think of a flywheel, where accumulated small incremental movements can eventually lead to the release of tremendous momentum that reinforces itself, and the pace of change accelerates when a critical mass is reached.

Small steps that occur over a longer period of time may be more sustainable than taking larger steps too quickly (go slow to go fast).

Leverage the organization as conversation perspective to gain momentum. How can you use rhetoric and patterns of relating and meaning to move change along?

Fail often to succeed sooner. Reframe failures into learning. Do not pass up an opportunity to learn from something that did not work.

Do the work of translation. Listen to your stakeholders to understand what the change means for them. Align your messages about change with their needs and interests (help them see what is in it for them).

Leverage high-quality relationships and robust networks to communicate about the true nature of change. Replace rumors with transparent, open communication about change.

Change requires endurance and optimism. Good self-leadership helps leaders to maintain focus and energy and remain committed to the change.

Continued practice at change and successful implementations of smaller change projects can build momentum for further innovation and change on a larger scale.

Over 2,500 studies of the diffusion of innovation have been conducted and support the idea that roughly 16% of any group will resist change. Leaders should focus not on that 16% but on the 84% that will move forward.

Summary

The complexity of transforming health care is daunting to even the most seasoned executives and clinicians. The traditions, culture, and knowledge base of the existing system are deeply rooted in the symbols, language, and behaviors of mechanistic, linear, and hierarchy-based organizational ways of being. Leaders of innovation and change must become habituated to new ways of being and doing (FIGURE 1-9). Leaders will need to develop specific skill sets, behaviors, and competencies to work effectively within the innovation–evidence–leadership framework. Understanding and leveraging the drivers that enable this framework will be integral to moving health care from its siloed and mechanistic structures to more dynamic, integrated, relational, and value-driven structures that can meet the needs of patients and providers today and into the future.

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