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Change for Tomorrow, Leadership for Today

Jeffery S. Vender, MD, FCCM, FCCP, MBA

The universe is change; our life is what our thoughts make it.

—Marcus Aurelius

Robert Byrne famously stated, “Everything is in a state of flux, even the status quo.” Like the weather (except in San Diego), change is a given. Today is a warm-up for the complex world of tomorrow. The past 100 years have been witness to dramatic changes. According to Google, the following statements describe life in the United States 100 years ago.

• Average life expectancy was 47 years.
  
• 95% of births occurred at home.
  
• Leading causes of death were pneumonia and tuberculosis.
  
• Most doctors had no college education.
  
• Iowa’s population was greater than California’s.

The 21st century is witnessing an accelerating and exponential rate of change. Information, data, and knowledge are reportedly increasing 100% every 5 years. Healthcare (critical care medicine) continues to face increasing challenges (demand and cost) that will result in inevitable change. Change can be as little as implementing a new electronic medical record, taking on new roles and responsibilities, or cross-training for a new job within the organization. Healthcare reform will result in changes yet to be defined. What will be the impact of the US Supreme Court decision on the Affordable Care Act regarding what care we provide in the critical care environment, to whom we provide this care, and how? As a result of the dynamic healthcare environment, numerous special interest groups, regulatory bodies, and nonregulatory groups are continually reacting to the circumstances and the challenge of faster (capacity), better (quality), and cheaper (cost) health care.

What changes will occur in our future are not yet known, but change will take place and the status quo will be a thing of the past. The key will be how the changes are made and by whom, and that will necessitate leadership with a capital L. Should politicians and special interest groups make the important decisions—what healthcare delivery system (critical care) is best, who should receive care, what therapy is best, what is the role of rationing? I believe that these decisions can be made only with strong medical input and medical leadership (more on leadership later) and a legitimately informed consumer.

Yes, change is coming, but will we be ready? Do we have the right leaders for the challenge at hand? The following is my attempt to provide a short synopsis on a vast topic—change and leadership.

Background Data

Writings on Change

Much of what is discussed in this chapter comes from the many books and papers I have read over the past decade. I have sought to identify some of the ideas and messages that I found enduring and not necessarily the most recent “fad du jour.” Like much of evidence-based medicine, the conclusions drawn from many of these written works often are not based on multiple large, blinded, randomized controlled trials. Some of the most popular and touted best-selling books about business, leadership, and change are based on a significant foundation of academic rigor, and their conclusions are simple and understandable. Yet many of the companies and individuals highlighted did not demonstrate sustainable results, with future corporate or individual performance falling below expectations. On an individual, not organizational, level, many leaders perceived to be great (by headhunters, search committees, newspapers) went on to be obvious failures (even criminals). Why the unexpected failure and eventual demise? It appears that most of the theories for success are predicated on the fitting of leaders to their historic performance, which might not be applicable to the dynamic complexities of a changing environment.

What to Change, When to Change

Knowledge changes. Situations change. Our attempts to predict the future are often futile. As Peter Drucker said, “If you want to predict the future, create it.” As we struggle to identify best practices, it has been shown that the diffusion of medical knowledge is slow, process guidelines often belie the complexity of the individual patient, compliance with best available evidence-based medicine varies, and our ability to acutely implement and sustain change is limited. Why? Because real change is hard work! This chapter is not intended to comprehensively regurgitate the volumes published on change and leadership. Instead I have tried to capture what I believe are universally applicable concepts and necessary skills for change and leadership, recognizing there is no single recipe for success.

The Social Science of Change

People don’t resist change. They resist being changed.

—P. Senge

Change typically results in an emotional reaction: these reactions can be quite positive, energizing, or exhilarating (eg, a salary raise, a new promotion, a diagnosis, or a medical cure). Alternatively, they can produce a negative reaction (remember the book Who Moved My Cheese), such as fear, anxiety, or panic (eg, “You’re fired). Much about the topic of change is based on the principles of social and behavioral science. In their book Switch, Heath and Heath¹ suggest that change necessitates attention to 3 components: The Rider, our analytic, logical interpretation of information; The Elephant, our emotional reaction to the situation and status quo; and The Path, the structure, systems, or environment created to effectively enable the change. Emotion (the Elephant) commonly overcomes logic (the Rider), as it is not easy to make an elephant go where it does not want to go. Yet emotion cannot take you where you need to go unless you know how to get there. As an example, we can look at caregiver compliance with hand-washing: Why is something so simple continually noted be so difficult to achieve? The Rider understands that caregivers can transmit bacteria from patient to patient. The Path has been addressed with structural changes by adding more sinks, hand gel dispensers, buttons, videos, and signs. However, have we reached the Elephant? Have we reached the emotional connection necessary to generate the personal and individual commitment to be accountable and compliant?

Many articles on behavioral science have addressed the concept of illusory superiority. A recent review by Davis et al² suggested that physicians have a limited ability to accurately self-assess relative to observed measures of competence. Similarly, Dan Ariely in the Upside of Irrationality shows the impact on people’s attitudes toward ideas and things.³ It is well demonstrated that individuals tend to overvalue their own opinions in comparison to how others value them. Positive self-illusion is at the heart of Garrison Keillor’s fable about Lake Wobegon. From the perspective of illusory superiority, we often recognize the problem or the need for change, but we do not perceive that we need to change because we are not the problem; the problem is always someone else (eg, nurses, administrators, government), because “we” are different, better, or right. J. Kenneth Galbraith, the prolific economist, was quoted as saying, “Faced with the choice of changing one’s mind and proving there is no need to do so, almost everybody gets busy with the proof.”

Why Do We Fail to Change?

Why do we fail to make necessary change? Some hope that the problem necessitating change will go away, forgetting that hope is neither a method nor a strategy. How often do we find ourselves diligently working and strategizing to do the wrong things better and better? Others have suggested that failing to change is a failure to see the need for change, failure to push change forward, or failure to finish the task (sounds like today’s government). Is failure to change due to arrogance, the bureaucracy of an inward-focused culture, fear of the unknown outcome, dysfunctional teams, or simply inadequate leadership? The reasons are many and not necessarily the same in any given situation.

Is It Real or Is It a Mirage (Perception or Reality)?

In the book The Forgotten Half of Change,⁴ Luc de Brabandere, Europe’s bestselling author on business innovation, nicely distinguishes the difference in 2 types of change. One type of change is a change to reality. The other type is a change to perception. The evolution of monitoring systems is a classic example of innovation or changing reality. In contrast, changing perception is the result of revolutionary development (creativity) resulting in a new reality. For example, laparoscopic surgery instantaneously changed surgeons’ and patients’ perceptions of cholecystectomy surgery, and FedEx changed our perceptions about the delivery of mail. The focus of this chapter is on changing and evolving our daily reality (leaving the creativity of the future to others). We already know that not everyone’s reality in critical care is the same. Why do some interpret ARDS Network data results based on the low tidal volume (<6 mL/kg), whereas others interpret the data based on a plateau pressure less than 30 cm H₂O? Why do some clinicians support selective gut decontamination? Are steroids useful in sepsis, and when? Under what circumstances does 24-hour intensivist coverage provide significant cost effectiveness? This list of questions is exhaustive and not complete. How we chose to interpret and implement available evidence-based medicine is often the answer to this problem and the root of our differences.

Fundamentals of Change

Perspective

How often are we convinced of the obvious, only to leave unappreciated the concerns of other key constituencies (eg, are the needs of pediatric and neonatal ICU patients more important than those of octogenarians)? How often do you look at an object or situation only to see it change when viewed from a different angle? Most elect to only see the angle that supports their view and blind themselves through an unwillingness to “change angles.” This issue was recently exemplified by the volatile controversy over mammography.⁵ Depending on self-interest or values, the face of the problem might change. This precipitates the risk of a more prejudiced interpretation or solution or, alternatively, the possibility of a more appropriate and effective one. Perspective provides breadth to the assessment of a given situation. When the perspectives of a broad list of stakeholders (eg, patient, hospital, insurer, society, and caregiver) are understood, a more enlightened decision is often made, creating the opportunity and willingness for better buy-in to the course of action or solution.

Focus

How often do we miss the lyrics because the music is too loud? Key communications on rounds are often missed because of the multiple and simultaneous comments and conversations occurring. Focus provides depth of thought to our analysis. Better listening, that is, listening to understand (key to leadership success), reduces the noncontributory noise and helps us hear the often overlooked solution or generate the next pertinent question.

How Should I Structure a Change Process?

The change process commonly begins with the recognition of a problem. Numerous texts propose methods to guide us through the process. Often it starts with a vision that is supported by several key elements: skills, incentives, resources, and a plan. If one step is missing, the process fails; for example, no vision creates confusion; no incentive (“what’s in it for me”) can result in resistance. In Leading Change, the Harvard Business School professor John Kotter⁶ nicely divided the change process into 8 understandable and logical steps that can be viewed in 3 stages (Table 9-1). By no means is this the only method for promoting and implementing change, but it does succinctly capture a number of elements that are often inadequately executed in failed change efforts. Each step is independent to the process, but the steps can be grouped based on their order of implementation: The first 3 steps are the warm-up, the next 2 steps are the roll-out phase, and the final 3 steps are the follow-through. Not appreciating the value of any one step can lessen the chance to attain or sustain consequential change. The rate of change (implementation) should be predicated on the true urgency for the change.

Table 9-1. Change Process

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Neuroscience in Pediatric Critical Care Considerations in the Determination of Death Critical Care in Resource-Poor Environments: The Reality and the Challenge Role of Simulation in Improving Patient Outcomes Costs and Reducing Waste in Pediatric Critical Care Control in Pediatric Critical Care

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