“We Change, or We Die”

Article · November 3, 2017

Watch Gary Kaplan’s health care leadership talk on leading in a time of adaptive change.


“I’ll never forget the day. I stood up in front of a room like this with 400 physicians and I said, ‘We change, or we die.’” A new CEO at Virginia Mason Health System 18 years ago, Gary Kaplan had already been with the organization for a couple of decades. “It was very challenging to take a new look from a new perspective and to build on a foundation that had been created over 80 years, and of which I was very proud,” he says. “But also, I had come to the realization that we needed to change. The trajectory needed to change. How to do that respectfully and lead large-scale change was the job in front of us.”

A willingness to challenge existing paradigms started with Virginia Mason’s board, who asked the health system’s leaders, “Who is your customer?” As would be expected, they answered, “our patients.” But the board replied, “It doesn’t look that way.”

Thus began the health system’s shift from a physician-driven organization to a patient-driven one. “We’re still fighting that battle today,” says Kaplan. “It’s still an open question. But one of the things we’ve learned is that you can’t change unless you’re willing to challenge the status quo, unless you’re willing to be open to thinking in new and different ways.”

Kaplan summarizes two types of change laid out by Ron Heifetz at the Kennedy School: technical and adaptive change. In technical change, the solutions to a problem are known and you can figure out how to get there. “Many of us cut our teeth as leaders being technical problem-solvers,” notes Kaplan. But much of change today is adaptive, he says, and associated with a sense of loss. For example, the electronic health record may feel like a technical change, but switching from writing orders in your own hospital to online order entry is adaptive.

Leaders have important roles in helping their team members adapt to change, says Kaplan. “We have to engage in humble inquiry. We have to genuinely be interested and listen and help our team members to realize that the solutions to adaptive change often lie within ourselves, within our team members.”

Health Care Leadership Requirements for Transformation

  Click To Enlarge.

Kaplan worked on a model of change with Jack Silversin and Mary Jane Kornacki, thought partners at consulting firm Amicus, which he calls Requirements for Transformation. The middle part of the model is what leaders do: focus on the technical and human, or adaptive, dimensions of change. Having an improvement method here, or a common language, is essential for leading large-scale change, says Kaplan. Virginia Mason’s method, called the Virginia Mason Production System, applies the Toyota Production System to health care and is similar to Lean.

“But that’s nowhere near enough,” says Kaplan. “Attention to the adaptive components of change essential.” These are:

  • Sense of urgency: It’s critical to “shine a bright light on opportunities,” says Kaplan.
  • Shared vision: If we don’t know where we’re going, together, we’re not going to have common purpose.
  • Aligned Expectations: “Let’s be explicit, let’s be transparent, let’s lower the water level and have the deep conversation about what we can expect from each other,” says Kaplan.
  • Visible and committed leadership: “Leaders have to be sponsors of change. That’s the single most important thing we do,” says Kaplan. “We have to do it with courage. We have to bring resilience. We have to be willing to listen carefully” — team members have the answers more often than not — and tolerate ambiguity.

Kaplan shares other lessons learned as a leader of health care:

  • The work is not about me. It’s about holding the organization in trust for the community and the people you serve.
  • Leadership is lonely. But having physician leaders and professional administrators working side-by-side in a dyad can be very effective.
  • Delegation is important, but you have to own the work. “Nothing is more important than how can we get better every single day to better serve our patients,” says Kaplan. “As senior leaders, this is our work, this is not work that we delegate.”
  • Leadership behavior drives culture. To lead a culture predicated on respect, one must model that respect.

Kaplan encourages leaders to think about the pace of change in health care. “This isn’t about figuring it out. It’s about building capability. It’s about being curious. It’s about tolerating failure because if we don’t fail enough, we’re not trying enough new things and we’re not learning.”

“I believe that the best years in health care are ahead of us. We’ve figured out things we never thought possible; let’s figure out a way to make that work so that everyone can benefit.”

From the NEJM Catalyst event Physicians Leading | Leading Physicians at Intermountain Healthcare, July 12, 2017.

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