MarieAnn North

If we do not change our direction, we are likely to end up where we are headed. (Chinese proverb)

I've learned a lot in my consulting career over the past 10 years.

I've learned that airline travel gets tougher every year, but that rental cars are better at getting me where I intend to go with the invention of GPS navigation systems. I've gotten better at constantly changing time zones, keeping up with e-mail, and packing two week's worth of belongings into a carry-on. At work, I've learned how to learn quickly, sort through massive amounts of data, ask the right questions, put together presentations that deliver a clear message, and stay on timelines. I've learned that I not only like my work, but I also like my clients and colleagues. They are for the most part highly intelligent, ethical, dedicated, wonderful people for whom I have both respect and fondness.

There's very little that still surprises me, with one exception. Clients engage me to implement change, but once I get started, they rarely want things to change. There seems to be a disconnect between the intellectual understanding that things can't remain as they are, and the emotional reality of what real change actually encompasses.

To be fair, I have chosen to work in the most complex of organizations. My client list is primarily top-tier schools of medicine and their associated faculty practice plans as well as academic medical centers-highly matrixed and confusing organizations. It may seem like somewhat of a contradiction to state that institutions that have achieved greatness need to change (in spite of their accomplishments and proud histories). Yet most of these institutions admit it takes massive amounts of energy to get things done, customer service could improve a notch or two, IT is decades behind other industries, the bottom line could use a boost as capital needs increase, and staff turnover is high and costly-from entry level to the faculty level as these institutions exhaust and defeat competent individuals due to their inability to simply get things done-simply.

So why does change have to be so difficult? Once we recognize obstacles that are inherent in our organization's culture, could we do a better job of changing cultures in favor of a culture of change?

Understand the Assumptions

Every organization assumes certain things "can never happen here." As an outsider, I am astounded that the physicians who believe they can cure cancer don't believe they can work in an ambulatory practice in which they see their patients on time. After a while, obstacles, inefficiencies, and underperformance are accepted and assumed to be inevitable. In leading change, I listen for the "moo factor." It's one of the few times I actually try to reach consensus with a leadership team. Do we all agree that "this" in fact is a sacred cow? If yes, then we don't need to waste our time on it. But it goes on a written list that we all sign. If that list gets too long, it's time for the consultants to leave.

When questioned, leadership often agrees that some things are extremely difficult to accomplish, unpopular, or may result in some fallout. But these things are not sacred cows, although they have held that status for years. These items go on a different list-a "really hard to do" list. Certainly in leading any change initiative, choosing items from this list alone sets the organization up for failure. There need to be some early and easy wins. But including a limited number of really-hard-to-do items is a must, and achieving success with these items encourages leadership to begin focusing on possibilities rather than obstacles.

Understand the Personalities

Certain personalities can hinder the change process, which is not to say that these same people aren't competent managers. They are not change leaders and risk takers. Physicians by nature are risk averse, and appropriately so. We don't want our medical staffs taking risks with patients' lives. When thrown into a change process, physicians will do what they are trained to do-question the data, build consensus, and wait out the symptoms. After all, the patient often improves with time.

Change initiatives succeed when the right people are at the table. Courageous and credible leadership is needed more than ever in times of turbulence. A successful change process requires both physician champions and administrative heroes. It requires individuals willing to give up an entitlement mentality, negativity, and/or whining, and to lead by example. If top leaders can't change, it's unlikely the organization will.

Understand the Organization

Nothing is as hard to overcome as culture. While some institutions understand the need to run a fiscally sound business, others struggle and don't see how they have become their own worst enemies. Many elements exist in our cultures-more so in the complexities of academic medicine-that shelter leaders from fiscal reality and make change processes difficult, if not impossible.

Often, I can't figure out where the real authority resides with these complex organizations-hospital CEO, school of medicine dean, board(s), faculty practice plan president, department chairs, etc. Everyone seems to have the power to say "no," and no one has the power to say "go"-a definite formula for failure. Confusion exists about board roles, which are often viewed as advisory rather than governing. There are many confusing matrix relationships, or lack of relationships. Service chiefs sometimes have no reporting relationship to hospital operations, although they have a substantial impact on the performance of those areas.

Leading Real Change

Change requires a burning platform, and organizations often are hard-pressed to find an example of one within their walls. Is debt really real? It's always been there, but it's business as usual. Deficit departments still have a checkbook, and some even pay bonuses. Faculty have tenure. How can there be a real fiscal crisis with absolute job security unrelated to performance? And what about that miraculous invention called a "new chair's package" that magically wipes out all sins of the past? If we take a long hard look at the cultures we have created, it becomes clear why change is so difficult and why so many desperately needed change initiatives fail.

Change is inevitable, whether we lead it or become a victim of it. So what are some of the solutions to leading our organizations through this process? What do we need in terms of leadership, management, risks, and rewards? It starts with changing the selection process of whom we choose as leaders. For decades, we've looked to the resumé-qualifications, skills, accomplishments, and experience. Not downplaying the importance of those items, nothing in this list recognizes leadership as a unique skill in and of itself. Leadership has nothing to do with being a great clinician. Nor is it a popularity contest. It's a skill set all to itself. Leadership requires skills in mentoring and coaching-something the majority of our organizations do not invest in, yet other industries believe in.

Creating a more nimble organization also involves looking at management differently. We've already stated that not all managers are leaders, so instead of moving people up to levels at which they can't perform, we need to move them "over." We create unnecessary silos when we keep managers in place for too many years. Perhaps a five-year term limit should be the way we operate-a revolutionary concept to some. People who can competently manage one area should be moved to a different area or department for the next five years. Eventually you have staff with longevity who are experts in many parts of the institution-who can collaborate and function beyond silos and self-interests.

It goes without saying that risks and rewards must be aligned to support change, but it's not always the case that compensation is at risk for performance. Is there downside risk, or is only the bonus at risk? Is it just about the paycheck, or does faculty need to earn perks such as protected time? Are there group incentives, or is it all about individual performance whether it benefits the overall institution or not?

Changing culture to that of a culture of change is the most difficult thing we will tackle and the most rewarding thing we will achieve. Our institutions need cultures that instill a bias for action and a comfort level with risk. We need to recognize leadership excellence and reward people who try something new rather than punishing them when they fail. There should be no reward for playing it safe when faced with today's challenges. A former boss with whom I remain friends quotes someone we don't often hear of in our hallowed halls-Larry the Cable Guy. "Git-R-Done" needs to be our new vision statement. Nothing is more rewarding and energizing than facing one less sacred cow.

MarieAnn North, FACMPE, is CEO, Posada Consulting, Charlotte, N.C. (

Publication Date: Wednesday, October 01, 2008

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