When Health Care Leaders Waffle...

The source for When Leaders "Waffle," Confidence Plummets is a little off the beaten path for this space, but Dr. Joseph Simone, one of my fellow Health Care Leadership Blog core contributors identified it and it's a great pick. Joe didn't have time to write - but had an itch about this piece and sent it along to me. So without having discussed it with him, I will take a stab at scratching for him.

The American Management Association, publishes a number of informative and topical monthly newsletters on management issues of which Leader's Edge, in which this short piece by Bruce L. Katcher appeared in May, is one. Dr. Katcher, an organizational psychologist, is an expert in employee opinion polling which makes his comments about the institutional impact of waffling particularly credible. While neither his focus, nor that of the American Management Association is on health care, waffling is a generic leadership condition to which health care leaders are far from immune. Katcher usefully informs us of the internal cost of waffling and counsels some prevention techniques.

Syrup or No Syrup...

Since the 2004 Presidential elections we've heard a lot about waffling and "flip-flopping." So we know it's supposed to be a bad thing. Indeed for John Kerry, no amount of syrup on the purported waffle was sufficient to make it edible. As politics is a rich medium for discussions of waffling, Katcher kicks off his commentary using the more recent example of how Timothy Geithner's "flip flopping" on how the federal economic bailout would be operationalized impacted economic markets. Despite attempts to characterize his conflicting statements as "flexibility," it engendered a lack of confidence in his leadership and in Katcher's words: "This was a good example of how poor decision making made a bad situation worse by bringing about a loss of confidence that then dramatically impacted the market."

Cooking in the Dark

The health care environment is nothing if not uncertain - perhaps more so than the economy. Given potential policy change potentially impacting reimbursement and organization of health care; the inevitable epidemiologic surprises; unpredictable professional work force dynamics; and rapidly emerging technologies in general - and the impact of the electronic health record specifically to name just a few, it is clear that the world of health care leaders is filled with multiple likely and widely divergent possibilities in the near and long run. While it's not always possible for health care leaders to unfailingly know where to go next, in order to keep colleagues, staff, and employees on board, it's important to move there with clarity and confidence. According to Katcher:

If employees trust their leaders and believe they make sound decisions, they will follow them even when they don't agree with their decisions. The key is that they believe their leaders can provide them with a clear, consistent direction...Our research shows that only one out of two employees believes the leader of his organization makes sound decisions.

Although health care leaders may be temporarily protected from employee defection by an unfavorable economy, when recovery inevitably occurs employees and staff won't be glued to their current organizations. As the "smart money" is now on investing in preparation or recovery, if they are already confident that their leaders charted a straight course through the bad times, they may be more likely to stick around, assuming the same leaders will do even better in good times.

Recipe for a Dark Kitchen

So while it's not likely health care leaders will know or do what's right in every circumstance, it is certainly possible to stack the odds and to be sufficiently thoughtful about the direction taken to avoid rapid and repeated waffling. Katcher offers some sound advice on how to do this. For health care leaders, particularly for physician leaders who are accustomed to making decisions relatively independently and sticking to them, these may seem like uncomfortable recipes, but Katcher's 3 step cookbook may fit these murky times:

1. Think before you act: Katcher means really thinking through the ramifications of decisions, communications, and operational approaches to responding to current conditions. As problems present themselves - be they impending reimbursement changes, real revenue shortfalls, market erosion, or quality lapses - it makes all the sense in the world to think through the available options and how to best implement and communicate them. Even if the best option ends up being a layoff, program elimination, or delay of a strategic initiative the way to get from here to there can either contribute to the problem or to the solution. I'm currently consulting to two organizations who are facing hardship in fundamentally different ways:

Leadership in an academic health center client is responding to budgetary shortfalls by forcing a reallocation of revenues from healthy Departments to unhealthy ones with little regard to promises and strategies previously in place. Different stories are told every day about how it is being done and This approach risks eroding the confidence of the best performers and threatening the organization's long term strategic interests.

Executive leadership in a large community hospital on the rebound from losses attributable to prior failed leadership engaged its physicians and executives in making the tough choices about where resources would be allocated and recovered handsomely from substantial operating losses despite the recent economic collapse. The executive management team persisted in funding a major future oriented electronic health record implementation despite the challenging economy. As a result, Staff and physician morale are high and the hospital system has positioned itself extremely well in a highly competitive market.

2. Check decisions with others before going public: Katcher wisely counsels that before making and announcing key decisions, leaders should first challenge representatives of key constituencies (in his opinion these would be optimists, pessimists, pragmatists and the cautious) to respectively indicate what they find most advantageous (optimists), risky (pessimists), challenging (pragmatists) or frightening (the cautious) and why they thusly believe. This means speaking seriously, and potentially in confidence, with those who may hold opposing beliefs. Only by taking a "360 degree" sounding can leaders reasonably anticipate the pitfalls and resistance ahead and frame decisions in a fashion that reflects due consideration to multiple points of view.

3. Fully communicate decisions

Even if steps 1 and 2 (above) are accomplished well, and tough decisions are arrived at with outstanding process, health care leaders typically fall down in communicating that process to stakeholder constituencies. If only the result is understood, leaders will be judged on the palatability of the decision. In challenging times, decisions are likely to be unpalatable. Acceptance, allegiance, and respect will only result from a well understood and communicated process that makes the alternatives considered - and rejected - clear and logical. Katcher informs us that:

"Our research also shows that only 38% of employees believe management does a good job explaining the reasons behind its decisions. Employees want to be treated like adults. They want to know why a decision was made, what the risks are, and what potential rewards they can expect. Most importantly, they want honesty from their leaders."

So as health care leaders we bear yet another burden. Not only do we need to present an appealing menu for customers and staff and execute it flawlessly, we have to anticipate what ingredients will become unavailable, when that might happen, how we will substitute new offerings with less fat and same taste, and how we will rewrite the menu in a way that continues to sound appealing and consistent with how we advertise our kitchen.

And all without the option of waffles.