The following post is by Derek Feeley, Executive Vice President, IHI
[Interview by JoAnn Endo, IHI’s Communications Specialist]
Q: What are the qualities of a good health care leader?
A: There are two prerequisites for being a good health care leader. First, you need a strong vision, a clear sense of where you are going and where you want to take your colleagues in your organization. Second, you need to have constancy of purpose, to persevere, to have the courage to stick with that vision.
As a leader, you are trying to strike the right balance between the short term and long term, and the right balance between activity and reflection. Some people want you to be thoughtful and consider options and issues, and others just want to see you act. So, you need to achieve a balance between those two things, in addition to finding the right balance between leading and managing. Management is an underrated skill, in my view, so making sure that leaders do the things they do as well as they can possibly do them — as well as making sure that they do the right things — are crucially important.
Leaders also need to create a balance between being resolute and being adaptable. Having that constancy of purpose, but also being willing to be flexible when it becomes clear that you need to change your path or find a better idea than the one you have been pursuing.
Q: You make it sound like leadership is a lot like parenting. Are there similarities?
A: I do think leadership is a lot like parenting — there are similarities. I was also a sports coach in my younger days. I coached rugby and I found I could transfer a lot of what I learned as a coach of a sports team to being the leader of an organization. You are trying to get the best out of people, trying to create an environment in which they can thrive. Leaders should be open to learning from life.
Q: What have been the keys to your success as a leader?
A: First, I enjoy reading what Warren Bennis writes about leadership. Bennis talks about leadership as being about getting people to want to do the right thing and I think I have been successful over the years in getting people to want to do the right thing. Some of that is about that clarity of purpose and the vision, but it’s also what I believe leadership to be about — my values as a leader.
For me, leaders should be authentic. They should be honest and transparent. They should be willing to celebrate the great stuff they see in their organizations, but they should also be willing to confront issues as they arise, things that aren’t going so well. So, authenticity is important.
Second, what has been important for me as a leader is approachability and visibility. If leaders spend all their time in their offices, they’re not really leading.
The third thing is that leaders should be inclusive. Leaders that take all of the leadership responsibility on themselves are rarely successful leaders. Leadership is a group thing; it is not an individual thing. I have tried to promote that value, to live that out, and to walk that particular talk.
Q: When you talk about helping people to do the right thing, does some of that have to do with explaining the vision, the goals, and everyone’s role in meeting those goals?
A: There are two parts to that. First, in health care, the constancy of purpose is really around patients and families, reminding people constantly that we are here for a purpose and that purpose is to provide better care and health for patients and families, and better value for every dollar that we invest. Just reminding people on a regular basis that we are here for that purpose is key.
The second thing is being able to translate the vision into actionable work. Helping people with what I like to call “line of sight,” from what they do on a daily basis through to that big picture vision that we’ve all got on our mind. If you can do those two things well, your chances for success are much enhanced in terms of getting people to want to do the right thing.
Q: How do you think your background in public service has influenced your work in health care?
A: I have been in public service longer than I care to admit, over 30 years, and people have this distinction that they make between policy makers and public service and practitioners — people who are out there at the point of care. I think it is a false distinction. I actually learned a lot about policy making that I am able to apply as a health care leader.
My previous job [as Chief Executive of the National Health Service (NHS) in Scotland] was an unusual one because part of the time I did make policy. I advised the Scottish government on what the policy should be, and the other half of my time I spent implementing those policies. I found that there are a number of things a leader could use to first make good policy and then effectively deploy those policies. Use the evidence is an obvious one. But there are also issues about judgment, about understanding the habits and traditions of the organization, about understanding the pragmatics.
If you are going to be an improver, you have to understand how to overcome opposition. Those issues about values and understanding how to deploy your resources are just as important in public service as they are in health care leadership and improvement. There is a lot to learn in both of those roles. Good policy needs to be embedded in good practice and it needs to be refined with the understanding of what good practice looks like. But good practice can’t operate in a policy vacuum either because that is where the connection to the purpose comes from, that is where the connection to the big picture comes from, that is where the sense of collaborative and collective effort rather than individual effort comes from.
Q: How has your experience leading the NHS in Scotland given you insights into how the Triple Aim and accountable care organizations might be implemented in the US?
A: I quite often speak to people about my experience as a health care leader in Scotland and leading the NHS and I always start by challenging them — especially here in the US, where people think that running a publically-funded, universal health care system in a relatively small country like Scotland must be significantly different from running a hospital system in the US, or anywhere else in the world for that matter. The similarities far outweigh the differences. Health care worldwide is facing a common set of challenges around the economic situation, the politics of health care, the demographics in the population, changing epidemiology, people are sick in a different way than we are designed to care for them, people’s expectations are changing, new technologies are changing — these challenges are the same everywhere.
What that means for health care leaders is that we have opportunities to learn from each other and those opportunities are significantly enhanced. These are big, serious challenges, but none of us face them alone. That is one of the reasons that as a health care leader I was drawn to IHI. IHI is a convener of expertise from all around the world, bringing together networks of experts and the best knowledge you can get. My motto has always been “steal with pride.” If I saw a great idea elsewhere in the world, I wanted to bring it to Scotland, and if we had something we were doing well I would want to share it.
Health care improvement is an open-source thing. We have the same problems; we should be sharing the solutions. The solutions to most of those problems exist in some part of the world; they just don’t exist for every patient, every time… yet. And that is the aim.
Q: In a recent Boston Globe article, several academics argued that, while charismatic leaders are what we're attracted to, what we really need are people who know how to get things done. The line in the article that really struck me was, “Inspiring leaders can make followers feel absolved of the responsibility to do anything hard.” What are your thoughts about that?
A: I think there is a role for charismatic leaders, but today leaders need to be adaptive. The challenges of the world now require leaders who can adapt according to the situation. If you are looking for a leader who is directive, then charisma and a “big stage demeanor” are really important. But if you are looking for a leader to be more in a coaching role, then you could argue that charisma is a disadvantage rather than an advantage because you want someone who can get on the same level as those they are coaching.
Leaders also need to delegate more. I have this sense that leaders of the future are going to have to be comfortable with complexity and generous with power because a lot of the solutions to the challenges we face lie in co-producing outcomes with patients and families and communities, or lie in the ideas of others. Leaders have to be big enough to be open to that.
Q: Would you say more about being generous with power, especially in connection with patients?
A: Some work we did in Scotland around supported self-management demonstrates being generous with power. We knew that for patients living with chronic conditions or long-term conditions, they are managing those conditions on their own for the majority of the time. They do not have a clinician in front of them; they have to manage their own conditions.
We had to tackle that problem, but frankly we did not know how. Instead of trying to assume knowledge of what those patients might need, we handed over the responsibility and some resources to the organizations that represented those patients, to the groups that came together to represent their interests, the groups that convened patients with diabetes, pulmonary disease, and other conditions. We said, “You write us a strategy, you come up with the ideas, and we will give you some resources to support those ideas through prototype projects and programs or to convene conferences and events.” We built some improvement capability in those organizations and the results they got were fantastic.
The awareness and the membership of people knowing how to manage their conditions grew exponentially in a way that if we, the health care system, had taken responsibility for that we would never have achieved the same results. Handing over the responsibility to the patient groups and saying, “You come up with a strategy and you run the projects you think will help achieve that strategy” turned out to be a really powerful thing to do.
The other thing that experience taught me was that the things we think are good outcomes for patients are not necessarily the same things they believe are good outcomes. Patients are just as likely to want the capacity to take their dog for a walk or visit their grandchildren, or attend a wedding or a celebration. They value those things almost as much — in fact, often more — than they value having their Hb1c in control, for example. It forces you to think differently about what you are trying to achieve.
Q: There is a lot of change going on in health care worldwide and many leaders, like you, are starting in new positions, working with teams that are new to them, or trying to make big changes in their organizations. What kinds of insights about your transition to IHI so far might be of interest to other leaders?
A: I have been lucky in my transition to IHI in that I have found a very welcoming environment. The key bit of advice I would give is don’t try to do it on your own. We are all facing a common set of challenges. We will all have something different to offer to meet those challenges. I would also say, be open to other ideas. Go and find people who are in the same situation you are, compare notes, build networks, try and generate a collective spirit around tackling these kinds of things.
Q: You mentioned before we started that you are sometimes impatient with the pace of change. How do you manage that impatience?
A: I am impatient largely because I am ambitious and that is something that leaders need to be. If leaders are not ambitious they cannot expect the people around them to be. So, I try to speak to people about my impatience and connect it to the ambition. I try to give them a reason about why I am being impatient. It is not that I have a short-term focus and it is not that I constantly need to see activity; it is just that I am trying to get us to a better place. I am trying to describe what that better place would look like. I am trying to plot a course from where we are to where we need to be.
The thing I try to do is to connect it back to the big vision, connect it back to our purpose as an organization. And then I think it is okay to be impatient because you have something that was collectively agreed to be worked on. You’ve agreed on it because it is good for patients and their families, and why would we not want to be impatient if what we are trying to do is make things better for patients and families?
Q: The other thing I am hearing in your answers, even though you haven’t used the word, is humility. What would you say to that?
A: Leaders need to be humble. It goes with the authenticity that I mentioned earlier. You are much more likely to be an authentic leader if you are a leader who listens, who is open to the fact that you will be wrong from time to time.
It is the type of thing that we teach when we teach the Model for Improvement. We teach people to try small tests of change and that they often learn more from tests of change that don’t work as compared to tests of change that do work. You have to be open to that as a leader as well. You have to be open to trying to make some changes, but you also have to be open to saying, “I might get that wrong, but I am going to try and if I get it wrong I will try something else, and if I get it right I will do it again.” I don’t know whether that is humility or just common sense — perhaps a bit of both.
