The LEADS in a Caring Environment Framework: Achieve Results

Abstract

No leader—certainly not you—goes into the health system to make the results worse! You, I and all health leaders envision a better future. We are always trying to improve results. That goal guides us through all the decisions and actions we take. In practical terms, much of our leadership energy goes to improving both efficiency and effectiveness [1],Chris Hodgkinson terms values as efficiency and effectiveness as “meta-values” of public service enterprises such as health, i.e., moral commitments that underpin the enterprise. Two other meta-values of health care in a universal health system such as Canada’s are equity and caring. where “Efficiency is doing things right. Effectiveness is doing the right things” [2]. This is where good leadership (doing the right things) meets good management (doing things right) to achieve results.

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Knowing is not enough; we must apply. Willing is not enough; we must do — Goethe

No leader—certainly not you—goes into the health system to make the results worse! You, I and all health leaders envision a better future. We are always trying to improve results. That goal guides us through all the decisions and actions we take. In practical terms, much of our leadership energy goes to improving both efficiency and effectiveness [1],¹ where “Efficiency is doing things right. Effectiveness is doing the right things” [2]. This is where good leadership (doing the right things) meets good management (doing things right) to achieve results.

Some results, of course, are more important than others. The Achieve Results is the most task-oriented of the five capabilities of the LEADS framework. It’s about focusing you on identifying which tasks matter most, showing you how to use them to set priorities, and then how to measure action on them to track success and set direction. Regardless of your role—CEO, mid-manager, front-line supervisor or community leader—Achieve Results will help you make decisions to identify priorities and take the actions to achieve them.

“The only vision worth pursuing is one that is impossible to achieve” Richard Farson says [3]. Nevertheless, pursuing a vision, and measuring progress toward it, should decide which direction you’ll follow, and the actions you undertake. “Health for all by 2020” has been adopted by the World Health Organization as its unifying vision, replacing “Health for All by 2000.” This is an example of a worthy horizon objective, likely unattainable but worth striving for. Either way, it can be translated into a series of measurable end-point and intermediate results that will give you points to navigate by in your journey as a leader. (It is one of the paradoxes of leadership that we need a clear vision to pursue, and concrete results to measure our progress and keep us on track, yet we may never reach our dreamed-of destination).

There are four capabilities in the Achieve Results domain:²

• Set direction

• Strategically align decisions with vision, values and evidence

• Take action to implement decisions

• Assess and evaluate

They are your navigational aids for setting a course to your vision. Let’s begin with the story of Janelle.

Janelle, in her first year as nursing supervisor, was trying hard to be an effective leader, and very committed to the concept of patient-centred care. She was excited to be asked by her manager to be champion for it on her ward. However, it quickly became apparent that some nurses on the ward did not share her enthusiasm. She could see why: the new program required significant changes in practice, meetings before or after shift; a new scheduling approach, and learning new clinical protocols. But there was also a critical shortage of nurses. Combined, they added up to an immense burden on the staff.

One day, Melissa, a friendly, dependable nurse who had recently transferred from another hospital asked to go for coffee. But as soon as they sat down, Melissa began to apologize. The words just poured out. “I have to give some bad news. I know how hard you are trying, and how much you believe in patient-centred care—and I do too, from an ideals perspective—but I can’t do it any more. I can’t balance the demands on me now: work, home, kids. I’ve had to take three extra shifts in the past two weeks to make sure the staffing protocol works, my husband is furious because he’s had to take two half-days off work when the kids got out of school early and I missed their piano recital last Saturday. Next month I’m supposed to go to Vancouver for a training session. I’m so sorry, you’re a great friend and I know you believe in this, but I just can’t do it anymore. There’s an opening back in my old unit and I’m transferring out.”

Janelle was shocked. Melissa had been a tower of support on the unit. She felt guilty too; she hadn’t thought of the impact of the change. She’d just thought—usually disparagingly—about how to deal with the nurses who balked at the change. “I know you’d probably like to talk me out of it,” Melissa said, “But my mind’s made up. I just can’t do this anymore.” With that, she walked back to the ward—to continue, as Janelle knew, to do her stellar work on behalf of patients.

That night, after talking with her husband, Janelle began to understand. Improving patient care—as a long term vision—was laudable. But was the goal attainable if it drove away the best nurses? When the job becomes a burden, burn-out, quitting or transferring are the options, none of which help the patient. How does a leader who cares for both the patient and the care-giver balance competing demands?

Janelle reviewed her conversation with Melissa. She realized she was so caught up in the promise of patient-centred care, she had not understood the impact it would have on her staff. She didn’t know if her staff understood the long-term benefits of the new approach, whether they accepted them, or whether they could actually implement it. She realized the resistance she was encountering from some of the nurses might be due to stress or burnout. To top it off, she had no idea Melissa had worked three extra shifts and had to go to a four-day training session. She was still committed to the vision, but more was needed.

Janelle was determined not to lose any more Melissas. She realized she needed to understand the impact patient-centred care would have on the nursing staff, and they needed to be given a concrete sense, with measurable markers of success, of how it would benefit patients. The plan also needed to include some “caring for the care-givers” by setting metrics to track the pace of implementation and gauge its impact and success. She would approach her manager and use data and evidence to help her understand the impact of the changes on the nurses. Otherwise, the patient-centred care initiative might fail altogether.

FormalPara Learning Moment

Take a moment to reflect on Janelle’s situation outlined in the story above.

• If you were in Janelle’s situation, what measures might you develop to assess patient-centred care that would resonate with other nurses?

• Like Janelle, leaders always have to balance ideals with the challenges of achieving them. Janelle decided her balance was off. Are you in balance? What would your colleagues say? Direct reports?

• Share Janelle’s story with a colleague. Are there lessons in her story that apply to leadership in your organization?

Janelle’s story contradicts the old adage that the ends justify the means. Putting patients’ interests first can sometimes translate to, or be perceived as, putting the interests of your team last. As a leader you need to possess a very clear sense of what success looks like both in the short- and longer term. You need to be guided by strong values and beliefs around how best to achieve sustainable results.

So now let’s turn our focus to looking at the four capabilities in the Achieve Results domain of the LEADS in a Caring Environment framework, and how together they can help focus your leadership on the task of improving health for our citizens.

Set Direction

Set direction is the first capability in the Achieve Results domain. We define it as “inspiring vision by identifying, establishing, and communicating clear and meaningful expectations and outcomes.” Visions can be leader-driven, management-team driven, or created collaboratively by engaging members of the organization; the latter approach is generally the most effective way to win broader acceptance for a vision [4]. After all, we own what we all help create.

What is clear from the work of a number of writers [5, 6] is that visions need to be inspirational in their own right about the better world you’re pursuing. However, if you have a compelling vision but can’t inspire others with it, you may find yourself in an uncomfortable place.

Strong visions enhance organizational performance [7], but even compelling visions expressed passionately may only inspire for a while, until reality sets in, and people start the hard work involved in realizing them. We’re willing to bet that after about 50 days at sea, buffeted by storms and running out of food, even Christopher Columbus had difficulty inspiring his crew by talking about China and the riches awaiting them.

Is it really different in health care? Sure, you can be inspired—as Janelle was—by ideals. But when the staff starts to grumble, good employees leave, hostility surfaces, and resources get scarcer, it’s difficult for anyone to remain inspired. That’s why it’s so important for a leader to identify clear and meaningful expectations and long- and short-term results, which can be measured to show whether the vision is being translated into action. Measurable results can give a distant goal relevance and infuse day-to-day efforts with meaning and purpose.

A second reason to establish and communicate milestones and expected results is that without them, we can lose sight of where we are at on the journey. A CEO who grew up in the Canadian prairies is fond of telling a story about growing up in Saskatchewan. Canada, like Australia, is a large country with vast prairies. It is a rite of adulthood that a young teenager growing up on the prairies is suddenly asked one day to take the wheel of the tractor and cultivate the field. My dad had been making great progress. The field was half done with nice straight furrows when he said to me: “Your turn, see what you can do!”

So I took the wheel of the tractor and carefully set off down the field looking backwards to follow his furrow. I got to the end of the field and turned to see how I had done. I was crushed to see that my furrow was as crooked as a dog's hind leg. I turned to my Dad and asked “So what did d I do wrong? How is it that your furrow is so straight?” He laughed and said: “Well, the first problem is that you were looking backwards the entire length of the field and every time you hit a rock in the field, it set you off course and you over corrected to get back on track. The trick is to look forward, not backward.”

“That’s fine then, Dad, but how is it that you get back on track so quickly that your furrows look so straight?” “Well,” he said. “I pick a fencepost on the horizon and I line up the tractor’s smokestack with the fencepost and that helps me to get back on track quickly when I hit the rocks in the field.”

The field of health care also has many unexpected rocks. Facing them, leaders need the fencepost of a compelling vision and a smokestack (benchmarks by which to gauge progress) to that vision. Here is another story to emphasize the point.

Grant was the CEO of a large national association, attending a meeting with leaders of other national organizations, to discuss how to work together on transforming Canadian health care.

During the discussion, another CEO named Brian interrupted. “What’s all this talk of doom and gloom?” he shouted. “We all know Canada’s got one of the best health systems in the world—just look at our neighbours to the south—they are envious of what we have. Why do we want to fix it when it ain’t broke?” Silence followed, and Grant found himself agreeing with Brian. “He’s right. I don’t think the situation has gotten that much worse.” But before he could say anything, Sharon, the CEO of a major nursing organization spoke up.

“I understand your frustration, Brian, but let’s be clear on what the real issues are. I care passionately about universal health care and the Canada Health Act. I also believe in our collective ability to fulfill its expectations. That’s why I go to work every day. But I believe the challenges—the doom and gloom, you call it—are real.

“I asked my research department to help me get a handle on what’s happening,” she continued. “The data they found indicate Canadian healthcare systems were on top of the world 10 or 20 years ago, but they’re not any more. Our health outcomes are down, our per capita spending is up and our international ranking is declining rapidly, which you can see in reports the OECD, WHO and the Frontier Centre for Public Policy all published in 2010. Combine their statistics with our aging demographic profile, and we clearly have some serious challenges.”

Sharon concluded by saying, “With all due respect, Brian, it seems to me complacency is our worst enemy—we need to pay attention to what these statistics are telling us. They’re saying we are moving away from our vision, not toward it—and it’s our job as leaders to work together to reverse that trend.”

Sharon’s answer shook Grant. He realized it was quite a while since he had looked at comparative data on his field, and wondered if it, too, would show the downward trend Sharon described. “I’d better get on that”, he thought. “Last thing I want is to be the captain of a ship that goes down on my watch. I’d better know what’s going on and what it means for our vision as an organization.”

The people in the room were all dedicated to preserving Canadian health care, but Sharon had data that showed they were falling short on achieving that vision. Armed with the facts, she could inspire them to take action, expressing her belief that they had the ability to meet the challenges the data represented. In order to speak truth to power, it is helpful if you have a very good sense of what truth is. Sharon was able to speak with authority and she did so in a compelling way. This is an example of set direction in action.

Learning Moment

Peter Senge, in his book, the Dance of Change ³ says complacency can be our worst enemy. He uses the parable of boiling a frog to illustrate his point: A frog in a pot of water brought very gradually to a boil never tries to jump out. But if it’s plunged straight into boiling water it does its best to leap away.

It is said that during change you’re either moving forward or moving backward—and in the health system, we’re always in the middle of change. What data do you have that could tell you whether you’re moving toward your vision or away from it?

As a leader, you set direction by:

• Establishing values that speak to the fundamental principles and ideals you and your people believe should guide your work together, and ensuring the culture of the organization reflects them.

• Defining, in collaboration with others, the shared vision you are working to achieve, then writing a mission statement that expresses the vision as a clear sense of purpose; and

• Identifying performance indicators for measuring whether you are adhering to your values and making progress toward achieving your vision.

Learning Moment: What Do Powerful Visions Look Like?

Business strategy and leadership writers offer some common characteristics for powerful visions:

• Concision

• Clarity

• Future orientation

• Stability

• Challenge

• Abstractness

• Desirability

• Ability to inspire.

Think about these questions:

• 1. To what extent do you believe visions in health care organizations are different from those in the private sector?

• 2. Are there characteristics of powerful visions that do not apply in health care?

• 3. Consider your organization’s vision statement in light of these characteristics. How does it fare?

The health system is a series of concentric circles, representing larger and larger playing fields in which you are expected to exercise your primary influence as a leader. Formal leaders usually have responsibility for leading in a specific field. Informal leaders choose where they wish to exercise influence. Each playing field needs boundaries—which are the values, vision, and performance indicators we’ve described. Because they are nested, formal leaders always need to align values, vision and key indicators across all the fields. Informal leaders face a similar challenge, but without the well-defined boundaries.

Strategically Align Decisions with Vision, Values and Evidence

The second capability of the Achieve Results domain is to strategically align decisions with vision, values and evidence. We define this as the capability to “integrate organizational missions and values with valid evidence to make decisions.” The key word is “decisions” because they are the currency of effective leadership. They represent the responsibility for setting priorities that comes with the leadership responsibilities of efficiency and effectiveness. Decisions are how you focus, direct and maximize the use of an organization’s resources to achieve its purpose.

Often, your credibility as a leader will be determined by how the people who act on, or are affected by your decisions, feel about them. They expect your desicions to align with organizational values and be practical. Chester Bernard, in his book The Functions of the Executive [9], contends all leaders have authority to make decisions within a particular “zone of acceptance” given to them by their followers. When leaders make decisions within the zone, the scope of the zone grows. But if they make decisions outside the zone it shrinks. Aligning structure and meaning is what establishes the boundaries of your zone of acceptance.

What do we mean by alignment? As a noun, it refers to “the degree of integration of an organization’s (or local service delivery system’s) core systems, structures, processes, and skills; as well as the degree of connectedness of people to the organization’s (or system’s) strategy. As a verb, aligning is a force like magnetism. It is what happens to scattered iron filings when you pass a magnet over them” [10].

Figure 7.1 shows how impossible it is to align vision, values and the organizational environment when there are no measurable results or valid evidence to keep the enterprise on track.

Fig. 7.1

Challenges of alignment without results and valid evidence

Measurable results and valid evidence to back them are missing from the diagram, and therefore, connectedness is missing, too. Measurable results help alignment by grounding the vision with measurable targets to assess progress and encourage effort. Valid evidence contributes to alignment because facts narrow the range of acceptable decisions. Leaders, like clinicians, need to use evidence to shape and support their decisions. Figure 7.2 shows how results and evidence contribute to alignment.

Of course, the linear image in Fig. 7.2 exists only in a perfect world. Leaders have to align multiple factors, including what other leaders are trying to do. Their collective efforts may support overall alignment but they may not. Ronald Heifitz [11] describes this as the challenge of “perfect understanding” and likens it to being on a balcony and on the dance floor at the same time. On the balcony you can see the whole and how it works together; on the dance floor, you’re dealing with the unique challenges of your own area. Measurable results and valid evidence maximize the potential for alignment, but can never achieve it. Complete alignment, like a perfect vision, is never possible, but the closer you come, the more efficient and effective your decisions will be.

Fig. 7.2

Shows how results and evidence contribute to alignment

Learning Moment

Consider the metaphor of being on the balcony and the dance floor at the same time. Discuss the following question with a friend or colleague:

• How would knowing the measurable results as defined by the board of your organization help you make decisions aligned with theirs?

• Do decisions in your organization clearly reflect valid evidence? Why or why not? How might this improve decision-making?

Take Action to Implement Decisions

Decisions without action are meaningless, yet it’s not unusual for decisions in health organizations not to be followed up on, which explains our third capability—leaders take action to implement decisions. Leadership is not simply knowing what to do and deciding to do it; by our definition, leaders “act in a manner consistent with the organizational values to yield effective, efficient public-centred service.”

Returning to Heifitz’s metaphor, being on the balcony means knowing what to do and how to do it while aligning all the factors of a complex health system; being on the dance floor is making sure it gets done according to your organization’s vision and values. It is about taking the steps necessary to make sure decisions made are implemented. Leaders also need to be good managers: as pointed out earlier in this chapter, they need to do things right as well as do the right things.

To be an effective leader you must understand the dynamics of change and turn that understanding into action others will support. “Walking the talk” matters: people judge us by our actions. When there’s a disconnect, our credibility suffers. So should you, to borrow a phrase from Nike, just do it? That isn’t easy for a lot of people. Knowing how to jump out of an airplane and jumping out of an airplane are two very different things. Fear must be conquered. Words found. New skills exhibited. Relationships altered. Comfortable patterns of behaviour changed.

Some interesting research done by Patterson and Grenny [12] suggests that action—in the form of implementing organizational priorities for change—can be stimulated by using their Influencer model. The Influencer model outlines specific actions to take to support action for change in your own area of responsibility. It actually combines capabilities of the Engage Others and Achieve Results domains in an artful way to create action. There are three steps to using the Influencer model.

• Step 1. Clarify measurable results

• Don’t waste time on how to create change until you’ve clarified what you want, why you want it, and when you want it. The result you are looking for will be:

  • 1. Specific and measurable. It is quantitative, not qualitative.

  • 2. What you really want. It’s the outcome that matters.

  • 3. Time bound. It comes with a completion date.

• Step 2. Find vital behaviour

• Vital behaviour exponentially improves your results. Crucial moments tell you when it’s time to act, vital behaviour tells you what to do and how to do it. Vital behaviour tends to stop self-defeating and escalating behaviour. It often starts a reaction that leads to good results. Here are the keys:

  • Behaviour is action

  • Behaviour is not results or qualities

  • Not all behaviour is equal

  • Only a few are genuinely vital.

• Step 3. Six Sources of Influence

• Your influence can trigger action when others are motivated to do something. However, motivation is not enough: they also must have the ability to act. The table below provides an overview of three levels of motivation and ability that must mesh together for action to happen. Patterson and Grenny [12] contend if you can respond in the affirmative to questions in four of the six cells, action will commence. It should also be apparent that if the answer to the questions is no, you know where to exercise your own actions as a leader to create the conditions for others to act.

Table 7.1 Six Sources of Influence

	Motivation	Ability
Personal	1. Make the undesirable desirable	2. Surpass your limits
	Questions to ask:	Personal ability
	Are they willing to engage in the behaviour?	Do they have the knowledge, skills, and strengths to do the right thing even when it’s hardest?
Social	3. Harness peer pressure	4. Find strength in numbers
	Social motivation	Social ability
	Are other people encouraging the right behaviour and discouraging the wrong behaviour?	Do others provide the help, information, and resources required at particular times?
Structural	5. Design rewards and demand accountability	6. Change the environment
	Structural motivation Are rewards, pay, promotions, performance reviews, perqs, or costs encouraging the right behaviour or discouraging the wrong behaviour?	Structural ability
		Are there enough cues to stay on course? Does the environment (tools, facilities, information, reports, proximity to others, policies) enable the right behaviour or discourage the wrong behaviour?

Leaders are always asking both themselves—and others—to change, to act differently from how they are acting now. It is one thing to take on that challenge for oneself (the Lead Self domain of LEADS). It is another to demand it of others. Change—big or small—is a consequence of having a vision for a better tomorrow, of improving the results we are all trying to achieve. Let’s review Melinda’s story, as an example of change:

Melinda was a director of maternal health with responsibility for all births in her city and the surrounding suburbs. Her supervisor, just back from a meeting with senior management, told her they’d discussed recent data from the Canadian Institutes of Health Information (CIHI) showing the local rate for Caesarian sections was 31 per cent, 5 percentage points higher than most comparable regions. The senior management team wanted to know whether it was time for action to reduce the number of C-sections and if so, how the organization would go about doing so. They wanted Melinda to put together a briefing.

Melinda’s research showed two physicians in particular who were responsible for almost half the C-sections. Other physicians in the region were spot on the provincial average. In addition, she found valid research that showed that regions where midwifery was part of obstetrical care had rates much below the average, lower costs, and fewer adverse events.

As she considered these findings, she realized both the physicians with exceptionally high Caesarian rates were very influential in the region. One was the husband of the chair of the board and the other was chair of the medical advisory committee. She also realized that to champion midwifery, she would have to recommend moving funds from the hospital to home and community care. The change would likely improve outcomes, but it would reduce the income of physicians doing obstetrical care, because they would deliver fewer babies overall, and do fewer better-paid C-section births.

“Can I recommend this?” she wondered. She knew her briefing note was going to get a lot of attention, and fallout from it — particularly from the two physicians most responsible for the high rates — could be particularly difficult for the CEO and chief medical officer. And the budget re-allocation wouldn’t be popular either. She wondered if her supervisor would even want to present the briefing note with those recommendations in it. It could be bad for her career.

Learning Moment

Reflect on how the Influencer model could provide Melinda with a plan for action.

• 1. What results does Melinda want to achieve?

• 2. What vital behaviour will determine whether or not she is successful? (Here the capabilities outlined in the Lead Self and Engage Others chapters will help).

• 3. What four sources of influence will assist her in achieving her goal?

Discuss with a trusted colleague or friend. There is no right answer; just the answer that would work for you if you were faced with Melinda’s challenge.

Melinda’s story shows us just how powerful culture can be and how leadership inaction or inertia often carries the day. Being a leader takes courage and always involves personal and professional commitment. Advancing the cause of maternal health involves a number of factors, only one of which is the actual number of C-sections. And the culture of the care delivery process can be a powerful opponent of change. In this case, the spectre of “once a C-section always a C-section” takes hold and it becomes very difficult to change the practice of physicians but also the preferences and attitudes of their patients.

Good leaders are aware of the need for authority and accountability to be aligned. Having accountability for delivering on results with little or no authority over the policies or programs to get the job done is one reason for the churn rate in senior leaders and why younger leaders are reluctant to take on more senior leadership roles. This is perhaps what Hans Selye, the great expert on stressors, had in mind when he used the term “stress of distress” [13]. And this is where good leaders are guided by the serenity prayer: “God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference.”

Assess and Evaluate

The fourth capability in the Achieve Results domain is assess and evaluate: “leaders measure and evaluate outcomes. They hold themselves and others accountable for results achieved against benchmarks and correct the course as appropriate.” Assess, evaluate and accountability are the key words in this capability. They describe the pointy edge of leadership—the process of knowing whether our responsibilities have been achieved, and accepting the consequences.

To assess something is to measure it. To evaluate something is to determine its merit or worth. A leader may need to know, for example, how many operations are being conducted in any particular hospital: that is assessment. Knowing how efficient or effective those operations are is an evaluative process—and one that is done by designing and employing benchmarks or targets to ascribe merit or worth to that result. All leaders in health care face measurement challenges. Some things—like spending—are relatively easy to measure. Other things—like caring for a patient, for an employee, or for self—are much harder to measure. Many of the benefits and costs of health care appear to be intangible. But they are not: it is just harder to find the appropriate measurement. Assessment and evaluation create the need for measurement and accountability, because measurement helps us be accountable. Accountability is different from responsibility, because you can be responsible for something but not ‘held to account’ for it. It’s important in leadership to be accountable for what you are responsible for.

Accountability has two forms. First, there is consequential accountability, which is accepting consequences, or being held to account for achieving your assigned responsibilities. The second is procedural accountability, which is being held to account for procedures and protocols that are expected to be adhered to, such as clinical protocols or financial protocols.

Holding yourself consequentially accountable for reaching benchmarks [14] means you’re accepting responsibility to make changes if the results don’t stand up. Many organizations establish benchmarks (that is, gauge acceptable performance by comparing results to certain standards, often data from other jurisdictions). They show performance relative to the benchmark on charts that make the implications of the data transparent. Many have policies dictating consequences if performance is significantly below par (we elaborate on one such model below). This kind of measurement formalizes accountability: “People live up to what they write down” [15].

When measures suggest significant changes are required, consequential accountability may conflict with procedural accountability. It may be the process is not being followed effectively, leading to poor results; or, the process itself may be unable to achieve those results. It is your job to ensure processes that should be followed are; or to change processes that don’t work, to improve results.

There are two measurement models you might wish to look at, one is the balanced scorecard created by Kaplan and Norton [16] which has significant traction in health care [17]⁴. A second is the triple aim construct promoted by the Institute for Healthcare Improvement in the United States [18]. Both models expect the leader to go beyond measuring financial results and assess results including customer or patient satisfaction, productivity (such as clinical accomplishments), employee engagement and how well important clinical practices are being implemented. The principles and procedures in both can be applied by leaders at any level.

Once you have chosen a measure, evaluate whether performance on it is satisfactory, judge whether action needs to be taken, and accept responsibility for undertaking that action. And finally, the more transparent you are—the more potential there is others will understand and support the action that needs to be taken.

Let’s review three examples of efforts to assess and evaluate performance to create effective accountability and corrective action.

The first example is the movement toward Accountable Care Organizations(ACO’s) in the United States [19]. ACO’s use population outcome data to assess and evaluate performance and then generate accountability by tying provider reimbursements to those quality metrics. Their purpose is to use data to reduce, wherever possible, the total cost of care for an assigned population of patients. Leaders who adopt an accountable care approach are aware they are accountable, through the linking of results to budgets, for the overall funding for and outcomes of the organization. The process supports improvement and provides confidence that savings are achieved when care is improved.

The Dartmouth Institute for Health Policy and Clinical Practice in Dartmouth College champions the concept of accountable care, created in an effort to end fragmentation of care and rein in costs. “To create a more sustainable system, we need a new model that holds health systems and providers accountable for the quality of care delivered to patients.” ⁵ The accountable care model promotes strategic integration of services and rewards, based on measures of quality. Better care not only benefits patients, it improves the financial picture for the organization and the people who work there. Accountable care organizations use data from the Dartmouth Atlas. It uses Medicare data to assess and evaluate the efficiency and effectiveness of health programs in national, regional, and local markets, as well as hospitals and their affiliated physicians. Accountable Care Organizations can set goals and accountability for them based on the data, and measure their performance against it.

Another organization that has converted measures and accountability into strategic action is Canadian Blood Services (CBS). Since 1998, CBS has used the Kaplan and Norton balanced scorecard as a lever to make the changes necessary to overcome the crisis of confidence in the blood supply caused by the tainted blood scandal [20]. The balanced scorecard uses financial measures for assessing and evaluating performance. But it’s important to note that financial concerns alone are not sufficient to guide change; it’s equally important for change efforts in health care to include developing long-term capabilities among employees and involving patients and citizens [21]. You must develop measures for all those factors, and assess and evaluate their implications and impact. Only with all those aspects balanced can an organization be considered on track.

CBS’s vision is clear and concise: “Canadians have trust in us.” Its mission is to “operate Canada’s blood supply in a manner that gains the trust, commitment and confidence of all Canadians by providing a safe, secure, cost-effective, affordable and accessible supply of quality blood, blood products and their alternatives.” It uses the balanced scorecard, adapted to its mandate, to guide strategic change. CEO Dr. Graham Sher says using metrics derived from the balanced scorecard’s four priorities (finances, program processes, human resources, and customer results) “…has improved our internal alignment, enhanced our metrics-based decision-making, and …(made)…allocating resources against priorities easier…In short, it has changed how we manage the blood system by crystallizing what’s important to our organization and its mission” [22]. CBS uses the balanced scorecard metrics to assess and evaluate progress and keep changes on track (it even measures openness in organizational culture) [23]. They developed their own measures, only looking outside the organization to help set targets when no internal data is available. The organization tracks and reports results quarterly; if it doesn’t meet a target, they discuss how to generate initiatives for meeting it [24].

Alberta Health Services (AHS), which administers the province’s health care system, publicly reports on 55 performance metrics. They look at everything from life expectancy, workforce absenteeism and wait times to whether the budget is on track and patient satisfaction. These are reported on quarterly. As well as being used internally to set direction for improvement, the public can also assess and evaluate how AHS is doing, leading to de facto accountability for the senior management of that organization [25].

Being able to “talk numbers” is a very useful leadership skill. It is essential in today’s health care to “count what counts” and to know how to use data to inform balanced decisions and action. In today’s health care, measurement and accountability are key to success and yet they must be approached with caution. A measure that shows performance consistently below average creates pressure for action, but under pressure you may not make the best choice of how to proceed. Focusing on a problem area at the expense of others that had been doing better is not unknown.

There are other challenges in assessing and evaluating. Sometimes (as in Melinda’s story) the action you have to take requires you to challenge the practices of important people. Will they resist, and do you have the skills to manage that resistance? Here the influencer model may be handy, as it provides a tool to plan for the situation—but obviously you must tread carefully.

There’s also the question of what you’ll do if your unit or organization consistently underperforms compared to its peers. When that happens, leaders can be tempted to fiddle their results to look good, which is what happened in the early 1990s when U.K. Prime Minister Tony Blair established maximum waits of 4 h in accident and emergency departments. To meet the standard hospitals had to attend to the needs of 98 % of accident and emergency patients within 4 h. If they did, they would receive a £100,000 performance bonus. The goal was well intentioned. But various studies [26, 27] showed admission rates spiked in the final minutes before the 4-h target as staff scrambled to clear cases from emergency. As well, sicker patients who might normally have been seen sooner saw their waits stretch as less-sick patients nearing their 4-h mark for waiting were attended to first.

Assessing and evaluating service is not straightforward, as this example shows. The imperatives of quality and quantity do not always align, but organizational values and culture must do so. And, in every instance the leader must look inside (Lead Self) for the guidance and fortitude to address the problem. It is a learning challenge; a change challenge.

Learning Moment

Reflect on the past 6 months. How often have you:

• Looked up measurable results and compared them to benchmarks and targets, to determine what mid-course corrections should be made within your area of responsibility?

• How balanced are the metrics you are using? Do they reflect the four categories of the Kaplan and Norton Balanced scorecard?

• How politically challenging is it for you to make change when armed with solid data and information? How might you overcome some of those challenges?

Conclusions

This chapter provides an overview of the Achieve Results domain of the LEADS in a Caring Environment framework and its four leadership capabilities:

• Set Direction

• Strategically Align Decisions with Vision, Values and Evidence

• Take Action to Implement Decisions

• Assess and Evaluate

Each of the four capabilities of the Achieve Results domain is aimed at clarifying and focusing you on the results of change, and on how to use those results to gauge progress and for course correction. In our experience, the discipline required to succeed in the Achieve Results domain, particularly for “taking action to implement decisions” and “assessing and evaluating,” is very challenging for modern health leaders.

We’ve observed that while measurement is often used effectively at the clinical level, it is used less effectively at the department and organization levels. That may be because of rapid amalgamation of small health units into big ones, requiring the coordination of disparate and fragmented data and information systems.

We’ve also noted that the rapid evolution of technology lets leaders develop information systems but does not necessarily prepare them for the politics of transparency and accountability. Even when good measures exist sometimes leaders are either unaware of them or reluctant to face the implications of them. It can be uncomfortable to be transparently accountable, with your performance out there for everyone to see.

When leaders are apprehensive about being accountable, uncoordinated information systems allow them to avoid it. However, the demands for sustainability, accessibility and quality in health care ensure measurement and accountability will not go away. Your challenge is whether you will take charge of the opportunities that assessment and evaluation provide, or wait for the government, media and the public to do it for you. All of us have to learn and change as the world around us, and its expectations, change.

Learning Moment

To use this questionnaire, find the right category for your level of leadership (e.g., front-line mid-management, etc.). Then assess how well you demonstrate the four Achieve Results capabilities, where “1” is I don’t do this well at all; “7” is I do this exceptionally well, and “N” is not applicable in my current role.

Which capability do you need to improve on? Why?

Table 2 Achieve results self-assessment