Why It Matters
Senior leaders can say, "We have a just culture," but high ideals can be undermined by the actions of a "blame and shame" supervisor.
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Leaders or Managers: Who Really Shapes Organizational Culture?

By Michael Pugh | Thursday, February 15, 2018
Leaders or Managers: Who Really Shapes Organizational Culture

Photo by Quino Al |Unsplash

Michael Pugh is president of MDP Associates and senior faculty for the upcoming IHI Quick Course: High-Impact Leadership - Developing Core Leaders. IHI recently spoke to him about how to develop the leadership skills of middle managers and clinical team leaders.

What is high-impact leadership?

Steve Swensen, Christine McMullan, Andrea Kabcenell, and I authored an IHI white paper called High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs. In our research, we wanted to determine the most advantageous areas of focus for leaders to achieve Triple Aim results for their organizations. We concluded that leaders need to do three things:

  • Adopt new mental models — How you think about a problem determines what you think of as possibilities for solutions. For example, the mental model you use when you’re trying to be successful in a fee-for-service world is quite different than if you’re redesigning care delivery to compete on value, rather than volume.
  • Learn new behaviors — Leadership behaviors shape culture. We did research with health care leaders across the US and internationally, and identified five behaviors that help drive and accelerate the rate of improvement in an organization: consistent person-centeredness; focus on vision and strategy; authentic presence at the front lines; transparency about results, progress, and defects; and systems thinking and collaboration across boundaries.
  • Adopt the IHI High-Impact Leadership Framework — Building on IHI’s legacy leadership models (including the Seven Leadership Leverage Points for Organization-Level Improvement in Health Care), the High-Impact Leadership Framework is an updated, simpler model that helps leaders determine where to focus efforts and resources to drive improvement and innovation. You can’t do everything all at once, so you need to prioritize.

Most leadership frameworks focus on executive-level leaders. What does high-impact leadership look like at the middle management level?

First, I want to note that many people don’t like to be called middle managers, so we call them “core leaders.” We’re talking about anyone who is in the middle: clinical team leaders, department managers, functional managers — anybody who answers to executive leaders and is responsible for overseeing clinical care delivery or support services.

Core leaders require the same leadership skills as executives, but they translate differently in daily work. For example — just like an executive — the manager of a laboratory needs to be an authentic presence at the front lines. For the laboratory manager, this means understanding the work being done in the department. They may defer to the expertise of the people working under them, but they should also understand how the work is supposed to be performed. They don’t have to be the scientific expert, but they need to know what’s working and what’s not.

Almost everybody has worked for someone they were sure didn’t have a clue. That’s the opposite of being an authentic presence. Being an authentic presence means getting out and getting close, making rounds. Good leaders can’t just stay in their office all the time. They’ve got to be out talking to their team and staff about the problems that they’re running into. They may not be able to solve all the issues, but core leaders must develop relationships. Their teams need leaders who care about what they’re doing, understand what they’re up against, and include them in decision making.

What makes core leaders so crucial to an organization’s improvement work?

The importance of core leaders has often been overlooked, but Dr. Deming supposedly said something to the effect that people who work in the process can tell you everything wrong with the process, but only the managers can improve it because they’re the ones empowered to change it. If you don’t include core leaders in the improvement work, or if they don’t have the right skills or knowledge to effectively make improvements, then you’re going to get limited returns on your efforts.

Here are the four things all core leaders should know:

  • How to manage the work — This means understanding how to measure and create standard work. They also need to know how to oversee budgets, processes, financial management, and other things which come with the jobs they were hired to do.
  • How to improve the work — They need to know how to use improvement tools and methods, and understand variation.
  • How to develop their team —This means knowing how to coach, communicate, delegate, and build relationships.
  • How to shape team culture — Many people might assume that shaping culture is a CEO’s job. I believe that core leaders have the biggest impact on the culture of an organization on a day-to-day basis. They’re the ones setting examples, playing out what the rules are, reacting to situations, and reinforcing what’s important. Senior leaders may communicate about priorities, but core leaders translate those messages. For example, senior leaders can say, “We have a just culture. We want to be blame-free," but if you’ve got a shift supervisor who has a “blame and shame” attitude, all those high ideals have been undermined by the actions of a supervisor.

How should executive leaders set up core leaders for success?

First, attend to their development needs. We tend to promote people that are technically, clinically competent into positions of management and responsibility, and then say, “Learn how to lead on your own.” In health care, we’re blessed with smart people, and most smart people figure things out. But it can be a struggle, and it’s a huge organizational waste when we don’t take the time we should to develop their key skills.

Second, executives need to model the high-impact leadership behaviors. If you’re promoting transparency, for example, as a senior executive, are you willing to talk about what’s not going well inside the organization? Are you willing to circulate the data? Are you willing to translate that data into both stories and into graphics that allow people to see what’s happening?

Then, when you move closer to the front lines and make your rounds, do you go right to the visual management board that’s on the unit and ask the staff about what’s on the board? Executive leaders need to lead by example. These are very clear leadership behaviors that core leaders can follow.

Some people have the attitude that says, “I got promoted. I figured it out. Why can’t they?” It’s true that, if you’ve hired the right folks, they’ll figure it out. But you could get from point A to point B a lot faster if you invest a little bit in helping people grow. It’s better for staff, and certainly better for patients.

Editor’s note: This interview has been edited for length and clarity.

You may also be interested in:

IHI White Paper - High-Impact Leadership: Improve Care, Improve the Health of Populations, and Reduce Costs

IHI Quick Course - High-Impact Leadership: Developing Core Leaders

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