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Lessons Learned in changing healthcare... and how we learned them November 2010 : 9-12

Introduction: Moving Forward Together through Reflection and Sharing

Paul Batalden

The pressure for changing healthcare is evident everywhere. Newly available data on excessive variation in quality, safety and cost are present in academic publications, disease registries, national scientific organizational reports, government-mandated reports and the published articles of numerous commissions and task groups. Personal experiences of disappointed patients, families and communities add a sense of urgency to the need for change.

All around us, people are at work leading change in healthcare. All of these leaders have a journey of experience from which they have learned (and are learning!) lessons. The lessons have developed in response to the wide variety of publicly available information, perceived challenges and conflicts, co-workers' desire for meaning and joy in work and personal recognition of better alternatives to the present situation – all part of the lived experience of leaders.

Sometimes leaders are perceived as acting in "reaction" to an external challenge, sometimes not. Sometimes "opportunities" are the apparent frame for action. Whatever the move taken and the thinking behind it, a leader's actual work offers an opportunity for learning and, if desirable, repetition. However, repeating what was once done may or may not represent the learning most needed. The what of change cannot easily be separated from the how of change for leaders who must take action.

Reflecting on what real leaders do – the challenges, the actions linking what and how and the ways in which all this has made sense – can offer insight into the "lessons in use," the learning that informs the daily work of leading and some of the potential sources of cultural entrapment that can accompany the "doing" of leadership work. How might we discover the lessons and gain knowledge from them?

Fourteen physicians were invited to reflect and give a presentation on the lessons they have learned while leading change in healthcare … and how they learned them. The lectures were held at the Dartmouth Hitchcock Medical Center in Lebanon, New Hampshire, U.S., from the fall of 2008 thru the spring of 2009 as part of a "Leadership Lessons" series. The invitees were working leaders in healthcare. We invited some who saw themselves as educators, some who thought of themselves as researchers and some who saw their work in the "operations" of healthcare. They all were individuals with local, and in many cases regional and national, recognition for their efforts to lead change in healthcare.

After identifying these individuals, we phoned them to invite them to participate. When told about the invitation, each one paused a moment. A clarifying question was often asked: "You want me to do what?" After the invitation was repeated, the invited speaker often said, "No one has ever asked me to give this kind of talk. I would have to think about it … I think it would be kind of fun." Fourteen people giving presentations with the same title – is this madness? Maybe, maybe not.

The gift that each of them gave was the product of their own reflection on lessons learned from their work as leaders. Each presentation was different. Each speaker identified specific learnings. As the speakers sought to identify and assign the causal systems involved in the particular lesson, we saw how variable the origins were: from signal experiences to influential mentors to organizational habits. Some found benefit from written materials which prompted the learning of the speakers.

When we invited these leaders to present, we shared with them our intention to make their reflections available to a larger audience via this book. To facilitate the preparation of the book, we transcribed the talks and shared the transcripts with the authors. We asked them to prepare a written version of the substance of their spoken message. We did not heavily edit their submissions. We want their words to reflect their way of communicating.

The messages are presented in the order in which they were heard. Attendance to the presentations grew as the series progressed, suggesting the appreciation of the community of Dartmouth Hitchcock, including caregiving health professionals, health researchers and health professional educators. Some attendees were young, and some were older. Some were established leaders, and some were working to become designated leaders.

The message of each contributor might be best appreciated by pausing briefly to note each writer's background and what they look like, which appear at the end of every chapter. Imagine you are placing yourself in the chair next to that person, ready to listen. Consider how the various contributors have framed their response to the invitation. All chose slightly different paths to relate the topic to events in their own life. Keep in mind the experiences that frame the situations in which the lessons were learned. The presenters had different ways of learning; notice how your own ways of internalizing lessons about leading change are similar or different. Make notes when the authors' messages are close to your own experiences.

When all the authors had submitted their chapters, we collated the learnings across the speakers and recognized that, together, they form a "tapestry" of lessons. We kept probing for the underlying threads that seem to weave themselves through the presentations, and we explore some of the most prominent in the last chapter.

Finally, step back from these presenters and their lessons and realize that in your own community, in your own network, a process similar to this one could be undertaken, allowing you and your colleagues to inquire of each other about the lessons that have been helpful to you. Explore how your particular setting contributes to the way change is learned and how it happens.

As we listened to these speakers, we realized that each of us can be invited to discover how the leader within each of us works: what has been learned, how it was learned, what has yet to be learned. We also appreciated that we can gain knowledge from the people all around us, and that conversation is a useful tool. Through introspection, we can recognize that each change leader has had to create a personal frame of understanding to make sense of what he or she faces as the processes of building knowledge, taking action and reviewing and reflecting become real. Naming the lessons and reflecting on how they were learned is an exercise in contemplation and self-discovery. Sharing these thoughts in conversation with others allows them to be examined, refined and further developed. The opportunity for learning about leading change in today's healthcare is all around us.

The collected lessons and how they were realized offer significant counsel for these times of change. But of potentially equal value is insight into the process of eliciting them. What we did in our local setting, you can do in yours. Everywhere that leaders are at work, there is the potential for a "learning laboratory" to help others develop their own leadership knowledge and skills. This is a book about leading from within the frames of personal experience and, through conversation and interaction, across them.

Whom should you invite? We asked physicians who are active as leaders; you could ask nurses, administrators, laboratorians, therapists, social workers, nutritionists, pharmacists – any healthcare professionals working as leaders. The key is the process of reflecting on the experiences: naming the lessons and exploring the means by which they were learned. Sharing them publicly enables others to see the real journeys involved in becoming a leader and, through conversation and interaction, to form communities of individuals engaged in that practice. Watching the process allows us to see that we are all immersed in the phenomenon of leadership development.

Thousands of books and articles have been written and millions of words have been spoken about leadership. This book is intended to invite a formative process for every reader and community. There is no claim of a "magic five realizations" – only the recognition of the truth that emerges from reflecting, listening, having conversations and connecting to the experiences of others within our own lives. Enjoy.

About the Author

Paul Batalden, MD, Director, Center for Leadership and Improvement, The Dartmouth Institute for Health Policy and Clinical Practice

Program Director, Leadership Preventive Medicine Residency Program, Dartmouth-Hitchcock Medical Center

Professor of Pediatrics, Department of Community and Family Medicine, Dartmouth Medical School

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