CHAPTER 4

The Adaptive Team

If you happen to be a jazz enthusiast, you are likely tuned in to how the best jazz bands seamlessly riff off of one another, adapting the music in the moment to create one effortless sound. While it may seem effortless to us as listeners and observers, it actually takes skill and coordination. The beauty of improvisational jazz is that the musicians create something new and unique, without having to start entirely from scratch. As the website apassion4jazz.net indicates, “The structure is flexible so that the soloist may venture in various directions depending on the inspiration of the moment. A jazz musician is creating spontaneous art every time he or she plays music.”

This notion of having a “flexible structure” is an important concept for health care leaders and teams. To be adaptive is not to say there should not be structure, consistency, or standardization. What it does mean is that leaders and teams must be equipped to first diagnose the situations, and then respond to the changing environment in as fluid a way as possible. Klein and Pierce liken adaptability to a team being dexterous, which in turn allows the team to have the capacity to improvise as events warrant (Klein and Pierce 2001).

In fact, the best health care teams already do this. Consider code response teams that come together to provide immediate assistance in cardiac cases, or the ED team that must quickly move from one case to the next, adapting to each unique situation as it presents itself. Certainly, procedures, protocols, and algorithms exist to assist these clinicians, but they also must rely on their intuition and experience, taking in information, properly assessing the situation, communicating effectively, while simultaneously being ready for the situation to change at a moment’s notice. This is the nature of many of our teams in health care, and it is not just limited to our clinical settings. Administrative teams face similar challenges as the environment continues to change rapidly. Consider the Affordable Care Act and the myriad changes it has brought about—accountable care networks, reimbursement based on value rather than volume, transformational care efforts, the Triple Aim, and so on. And the stakes are getting higher. The ability of leaders to appropriately diagnose and respond to these challenges is paramount.

Because of this constantly changing environment that is so prevalent today, our teams need rigorous and relevant models that assist them with navigating change. This chapter will introduce health care leaders to the most current, cutting-edge models that deal with leading and adapting to change. The fields of complexity science and developmental psychology will form a foundation of practical tools that can be used to more fully engage teams in identifying and responding to challenges. Examples include the use of liberating structures (LS) (practices that engage team members in creative ways and at the same time increase shared ownership and appreciation for different perspectives), and a model of developmental readiness, where team members identify their motivation and ability to learn, grow, and develop.

Strategies to help teams be more adaptive:

Assess and Understand the Environment

As has already been discussed many times, the health care environment continues to evolve and change at a breathtaking pace. The challenge is that leaders and teams have not experienced this degree of complexity, and many are not adequately prepared to respond to it. Rapid technological changes, attempts to integrate disparate electronic medical records (EMRs), public reporting of quality, safety, and satisfaction results all make for a world that is much more complex for today’s health care leaders and teams. And what’s more, as the degree of complexity and uncertainty continues to rise, the frustration of these players mounts.

As a first step to increasing the ability to respond to this ever-changing environment, we recommend conducting an environmental scan, a practice that has long been used in traditional strategic planning efforts to help organizations more fully understand the factors (internal and external) that could impact their future activities and actions. When conducting an environmental scan, it is advantageous to include all members of the team in order to gain as many different perspectives as possible. Examples of factors to assess from the perspective of the internal environment include: policies and procedures, changes in senior leadership, adoption/implementation of new technologies, cross department interactions, finances, and so on. Examples of factors to assess from the external environment include: regulatory changes and trends, the political climate, research and development, social trends, and so on.

In fact, there is evidence that suggests the more an organization is in tune with its surrounding environment, the greater its longevity as the organization tends to be “more in harmony” with its environment (De Geus 1997), and is better able to respond and react to changes.

The importance of assessing and understanding one’s own environment is no less important today; what has changed is that we need to be much more discerning about the lenses we use to view this complex, multicolored environment. If we only consider the environment based on our own biases and views of the world (what we know to be true), we will undoubtedly miss something. And that something we miss could have a vital impact on the team or organization down the road, not to mention the patients we care for.

So what can we do to expand, or broaden, our perspective in this area? Earlier in Chapter 3 we introduced the principle of suspending assumptions, as well as the metaphor of “going to the balcony” (Ury 1991); we would now like to highlight this concept in more detail as it applies to assessing and understanding one’s environment.

Essentially, the idea of going to the balcony involves removing oneself from the attachment of being “in the thick of it all.” Consider a crowded networking event in a large conference hall where dozens of people are mingling and getting to know one another. What is your experience like as a member of this moving throng? Likely, you are focused on what is right in front of you—the person you have just met and the conversation you are engaged in. Your brain is also likely forming immediate impressions of these other people, and determining whether you would like to continue speaking with them because you have mutual interests and you find them fascinating, or whether you should move on to the next person.

Now imagine there is a small balcony located 30 feet above the conference room floor. You decide to make your way to the balcony to get a break from the networking. When standing at the rail of the balcony and looking down on the event, what happens to your perspective? What shifts for you? What do you see now that you couldn’t see before? This is the nature of “going to the balcony.” It requires a deliberate and specific shift in mindset. It forces us to ask the question, “How can I see this differently? How can I change my perspective?”

On the surface this may seem like a simple exercise. In our experience, it is anything but that. Suspending our existing biases and beliefs is not easy at all. We tend to automatically default back to what is known and what is comfortable. Our biases remain prevalent. Of course the good news is that, while these biases do in fact exist, we are not beholden to them—we can make deliberate choices to act or behave in ways that free us up from our biases.

A good example of the inherent difficulty in shifting our perspective is the Harvard Implicit Association Test (IAT) (Greenwald et al. 2002; Greenwald, Nosek, and Banaji 2003). A group of educators and researchers from multiple institutions collaborated to create a battery of questionnaires to help us see where our actual unconscious biases lie. Do you associate women with career or family? Do you associate a photo of an African-American male with a positive or negative word? Having this knowledge increases our awareness of the biases that are actually at work, and gives us the opportunity to respond in new ways.

In his three decades plus of studying human development, Robert Kegan has hypothesized three main levels of adult development: the socialized mind, the self-authoring mind, and the self-transforming mind (Kegan and Lahey 2009, 2016). When we are at the level of the socialized mind, it is akin to being in the middle of the networking event (or dance floor, depending on your preference) and being emotionally and mentally connected to the other people you come into contact with. You are able to have engaging conversations, but it can be difficult to remove yourself from the content of the conversations. It can be easy to get sucked into what the other person is saying, contemplating your degree of agreement or disagreement.

With the self-authoring mind we find it easier to objectively assess the content of the conversation and perhaps consider (from a standpoint of curiosity) what biases, values, and belief systems may be informing the person’s commentary and perspective. This type of thinking gets us closer to the balcony.

Advancing to the self-transforming mind gets us all the way to the balcony. Perhaps even beyond the balcony. We are able to see things with new clarity and to consider a perspective we would have previously been blind to. We are able to both assess and understand our biases and filters, examining them in a more objective way. It is this level of self-assessment that frees us up to make different choices. As Kegan and Lahey put it, a self-transforming mind “is aware that what might make sense today may not make as much sense tomorrow” (Kegan and Lahey 2016).

In reality, we are never able to completely remove or dismiss our biases, for they are deeply ingrained. However, heightened awareness of our biases allows us to see things from a new perspective. Therefore, moving to the balcony while conducting an environmental scan truly allows us to consider the world around us (and what is consequently impacting us, or likely to impact us) from the broadest perspective possible.

Another methodology that can be useful when assessing the environment is to consider the environment through different frames, or categories. Examples of different frames include: political, regulatory, science, technology, social networking, communication, and so on. Asking people to pick a frame, researching what is going on in that area, and then reporting back to the group can be a useful way to accumulate a broad array of information about the various frames selected.

We have found that when working with teams, simply engaging them in a dialogue about what they see happening in their world (internally and externally), and the possible implications, serves to (1) diversify the perspective of the group and (2) create a shared understanding of what is happening around them.

Assess the Nature of the Challenges

In Chapter 2, we focused on the importance of teams being able to learn, and we introduced the concept of adaptability. Dr. Ronald Heifetz and Marty Linsky of Harvard have introduced a leadership approach known as adaptive leadership, and it is something we all need to be paying greater attention to. One of the core tenants of Heifetz’s model is being clear about the distinction between technical problems and adaptive challenges (Heifetz, Grashow, and Linsky 2009).

Technical challenges are known. We have proven methods, processes, tools, and approaches with which to tackle these problems, and we can be reasonably assured that our efforts will result in success. Examples of technical problems include installing a new piece of equipment, repairing existing equipment and instruments, refining a purchasing process, or generating a new report. Or as Heifetz would say, technical problems “live in people’s heads and logic systems. They have clear-cut solutions and can be solved with knowledge and procedures already in hand” (Heifetz, Grashow, and Linsky 2009).

With adaptive challenges, things are not as straightforward. Solutions are not so readily available, or when we apply a solution that we think should work (because it worked before) it fails miserably and we aren’t sure why. All of a sudden people don’t know what to do, and it becomes easier to avoid the problem altogether, or impose a solution, even though we know it’s only a band-aid solution. In these instances, new knowledge is required; new models, methods, and approaches must be considered. In other words, new learning is required here. Adaptive challenges tend to be most prevalent when behaviors, values, and belief systems are challenged. Whenever people talk about the need to change the culture, you have an adaptive challenge on your hands. Examples include forming a new team, and implementing a new process that significantly changes how people have performed or behaved in the past. (See Table 4.1 for a comparison of adaptive and technical challenges.)

Table 4.1 Technical vs. Adaptive challenges

Heifetz argues that a significant leadership failure is addressing adaptive challenges as though they were technical problems. And of course, this makes sense. We are frequently creatures of habit and it is comfortable to use approaches that have worked in the past and that we therefore believe should work now. So the first step for leaders is to simply recognize this distinction between technical and adaptive challenges.

Try New Things—Experiment

When a large outpatient specialty center decided to move to a new location and expand their operations, leadership also wanted to implement patient self-rooming. The various clinics had never used this process before and everyone was worried that their patient satisfaction scores (which were excellent) might suffer as they implemented this new process. After having additional conversations they decided on the strategy of enlisting their patients as participants in “trying out this new process.” When a patient arrived to check in at the center, they were offered the opportunity to participate in the new, innovative process of self-rooming. The front desk staff would explain the new process and ask the patient if they would be willing to give it a try, and to also provide feedback so the clinic staff could continue to refine and improve the process. The patients were also told they did not have to participate if they did not wish to, and in such cases a medical assistant would room the patient.

Using this approach accomplished several things: it allowed the staff to turn control over to the patient, so the patient didn’t feel put upon by the change, and it put the staff at ease since they knew the patient could decline if they so desired. Ultimately, many of the patients ended up participating in the new process, and the clinic was able to continue to make improvements.

In high school science classes many of us experienced lab sessions where we had the chance to actually see the theories we were learning applied in an actual experiment. It was a chance to try something, see how it worked, and then learn from that process. We need to create more opportunities for our teams to try new things—to create and innovate. Leaders can set the stage for trying new things by encouraging teams (and individuals) to try a small test of change. We sometimes mistakenly believe that trying something new, or experimenting, requires a massive change. This is not the case at all. In their book, Immunity to Change, Robert Kegan and Lisa Lahey encourage individuals to conduct small experiments and then see what happens. It is akin to dipping a toe in the water, rather than jumping in the deep end (Edmondson 2012; Kegan and Lahey 2009).

Generate Engagement at all Levels

The thing about adaptive challenges is that they do not lend themselves well to a single person working on them. You need to get others involved—you need to mobilize others to think and act. This is a core element of Heifetz’s approach. The practice of LS, created by Keith McCandless and Henry Lipmanowicz, offers us unique ways in which to engage people at all levels of an organization, but the strategies work especially well with teams. The tagline on their website (liberatingstructures.com) reads, “Including and unleashing everyone.” Their approach is grounded in complexity science and places a premium on self-organizing, learning processes. McCandless and Lipmanowicz argue that most of the structures and organizing principles present in our organizations today typically do not generate engagement and open dialogue. Oftentimes leadership or a committee has come up with “the solution” that is then imposed on the rest of the group or organization. While the intentions of these leaders and committees are noble, the result of these actions often leads to resistance, doubt, or apathy.

McCandless and Lipmanowicz created 33 LS (sometimes referred to as microstructures) and they are all available on their website and can be used free of charge (they only ask that users recognize their work). Clicking on a given structure provides a detailed description and purpose of the structure, along with guidance on how to actually use it. Let us share an example of LS in practice to illustrate.

An executive master of healthcare administration (MHA) student used the LS “TRIZ” to engage her ER team in examining why it was taking so long to transfer patients from the ED to the OR for the surgical procedure (in many cases, it was over an hour, and the surgeons were getting extremely frustrated). The premise of TRIZ is to get a group to consider all of the different ways they could make their initiative or project fail—yes, fail. Teams generally enjoy this process as they are free to consider all of the plausible, including what can seem downright ludicrous, ways their work could be sabotaged. But the process does not end here, in fact it is at this point that the heat gets turned up a bit. Participants are then asked to review the behaviors on their list, and call out any that they actually engage in. This is a critical moment in the process, and there is often a short period of silence until a brave soul will declare, “Yes, I sometimes do that.” It usually takes just one person to break the logjam, and then everyone (or almost everyone) joins in. Here is how the MHA student described her experience once she asked this question of her group:

This is a fantastic example of engaging a team in a creative way to address a problem. Rather than the leader developing “the” solution, the group owned the process and as a result the members were able to identify possible solutions and implementation strategies.

In speaking more with this student, she expressed how helpful it was to first diagnose the situation in terms of technical versus adaptive problems. By being clear she was dealing with an adaptive challenge, she recognized she would need to use a different approach to engage the team. In addition to applying the LS TRIZ, she also leveraged the change model Switch from the book by the same name, written by Chip and Dan Heath. She used specific elements of that framework (namely Script the Critical Moves, Find the Feeling, and Grow Your People) to allow the team to fully own the problem and generate the solutions. She was amazed at the energy that came out of the team as she facilitated the process, and the number of ideas generated was more than she imagined. The team established a goal of 45 minutes to transfer the patient from the ED to the OR. They tested their new process (think experimentation), tracking the results of each transfer. At the end of the two-week period, she brought the team back together to reveal the results (in a sealed envelope, no less) and discovered they had surpassed the 45 goal with an average time of 36 minutes. The team was thrilled, as were the surgeons.

A key element to this success story was the willingness of the student to take on the role of facilitator for the team. She was able to pay attention to process but, more importantly, her knowledge of these tools gave her a way to engage the members of her team in ways she had never before considered. The success of the effort speaks for itself.

The intent of this section was to provide an example of the power of involving the people closest to the work in both understanding the problem or challenge, and then generating solutions to test. In 2012 a group of researchers concluded an 18-month study of engaging front-line staff in generating solutions to significantly reduce hospital-acquired infections (HAIs) at five Canadian hospitals (Zimmerman et al. 2013). Using a combination of LS, as well as other employee engagement strategies, the researchers involved the clinical staff closest to the problem and saw improved results across the board. They named their approach FLO, front-line ownership, and published an essay outlining this approach. At the end of the study they observed that the rate of infection (measuring the combined organism rate) decreased by nearly half on the units involved in the FLO initiative. As a result, the authors of the study offered the following insight:

Foster a Culture of Learning and Development

Clearly there are strong linkages between learning and adaptation. In fact we would argue that you can’t have one without the other. Therefore, in order to have an adaptive team, as this chapter calls out as an important factor in leading health care teams, leaders need to pay particular attention to how they are creating the conditions for learning to thrive as part of the culture. In Chapter 2 we focused on the elements needed to help teams adopt a learning framework:

We would now like to build on this thinking by addressing the cultural aspect of this work.

A close colleague of Kurt once stated, “Leaders own culture. And it is an irrevocable responsibility.” This is a powerful statement and, if you believe it, carries many implications for today’s health care leaders. So how does a leader (or collection of leaders) go about influencing the culture such that an environment of continuous learning and development exists and truly thrives? We offer the following thoughts on this topic.

Before proclaiming that you will create a learning culture, it would first help to understand the forces that prevent us from learning in the first place. Consider your own organization for a moment and note the barriers that exist to the occurrence of continual learning—items you might identify could include the following:

These factors have a strong influence on us and are present in many (if not most) health care organizations. Certainly there are pockets where one would not encounter these inhibitors, but by and large, we are challenged with these barriers. Amy Edmondson addresses this by stating that we need to “learn to learn from failure” (Edmondson 2012). To be clear, she is not glibly stating we need to merely learn from failure. She is saying we need to learn to learn from failure. The potential barriers to learning just listed act to counter learning from occurring. Therefore, we advocate for addressing these barriers head on, rather than hoping they will go away or that they do not exist. And we believe the best way to do this is by engaging teams directly in conversation about the barriers that exist to learning. Using strategies from LS can be a useful and productive way to call out and address these barriers. In fact, using the LS TRIZ could be one effective way to generate dialogue about barriers and what needs to be done to reduce or eliminate those barriers.

Kegan and Lahey provide the most current examples of efforts underway to create what they call “deliberately developmental organizations” or DDOs (Kegan and Lahey 2016). Without going into extensive detail here (we highly recommend reading their book), one of their key findings in studying three DDOs is that they were able to effectively blend, in a very intentional way, the work of the business (operations, processes, and outcomes) with individual development. In fact, Kegan and Lahey believe that the DDO framework may be the most important factor in responding to adaptive challenges (p. 6).

The bottom line is, if leaders commit to fostering a culture of learning, they need to be fully engaged and must model the behaviors they wish to see in others. It is not just about making learning a priority (framing, as Edmondson calls it (Edmondson 2012)), but also about making it relevant, engaging, rigorous, and fun. Some suggestions for creating a team learning culture include:

In Summary

Building the adaptive capacity of your teams will be critical for thriving in today’s complex health care environment, and we have offered but a small number of considerations. However, in our effort to share some of these strategies, we have been deliberate in tapping into what we consider to be some of the more current and leading-edge theories and models for creating adaptive teams. Certainly there are other models and perspectives out there—regardless of what strategies you choose to adopt, our main hope is that you do so in a deliberate way that engages people in meaningful ways.

Furthermore, by focusing on the activities of assessing the environment, determining the nature of the challenges you are facing, experimenting, generating engagement at all levels, and fostering a culture of learning, you will be creating the conditions for your team members to assume ownership for their work, which is the topic of the next chapter.

End of Chapter Reflective Questions

References

De Geus, A. 1997. The Living Company: Habits for Survival in a Turbulent Environment. London: Nicholas Brealey.

Edmondson, A.C. 2012. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. John Wiley & Sons.

Greenwald, A.G., M.R. Banaji, L.A. Rudman, S.D. Farnham, B.A. Nosek, and D.S. Mellott. 2002. “A Unified Theory of Implicit Attitudes, Stereotypes, Self-Esteem, and Self-Concept.” Psychological Review 109, no. 1, p. 3.

Greenwald, A.G., B.A. Nosek, and M.R. Banaji. 2003. “Understanding and Using the Implicit Association Test: I. An Improved Scoring Algorithm.” Journal of Personality and Social Psychology 85, no. 2, p. 197.

Heifetz, R., A. Grashow, and M. Linsky. 2009. The Practice of Adaptive Leadership. Boston, MA: Harvard Business School Publishing.

Kegan, R., and L.L. Lahey. 2009. Immunity to Change: How to Overcome it and Unlock Potential in Yourself and Your Organization. Harvard Business Press.

Kegan, R., and L.L. Lahey. 2016. An Everyone Culture: Becoming a Deliberately Developmental Organization. Harvard Business Review Press.

Klein, G., and L. Pierce. 2001. “Adaptive Teams.” U.S. Army Research Laboratory sponsored report.

Vogt, E.E. 1995. “Learning Out of Context.” Learning Organizations: Developing Cultures for Tomorrow’s Workplace, pp. 293–303.

Wong, L. 2004. Developing Adaptive Leaders: The Crucible Experience of Operation Iraqi Freedom. Carlisle, PA: Strategic Studies Institute, US Army War College.

Zimmerman, B., P. Reason, L. Rykert, L. Gitterman, J. Christian, and M. Gardam. 2013. “Front-Line Ownership: Generating a Cure Mindset for Patient Safety.” Healthc Pap 13, no. 1, pp. 6–22.