Mary Jane Kornacki, MS, interviews Edgar Schein, PhD, Society of Sloan Fellows Professor of Management Emeritus and Professor Emeritus at MIT Sloan School of Management, recorded live at Stanford in Palo Alto, California. Part 2 of a 2-part interview. Catch up on Part 1.
Kornacki: I want to switch gears a bit. The other domain in which you spent so much time writing and thinking and observing is culture. Culture continues to be a barrier to change in many of our medical organizations, and I’m wondering if you have any insights for leaders at the various levels of an organization, the top and people who are running teams or divisions. How does culture change? That still is a question we struggle with in health care.
Schein: Unfortunately, culture is built by leaders when they first start an organization, and culture changes with new leaders. What I’ve seen in a number of hospitals — and we put a couple of these [real] cases in our book — is that a leader comes in and wants to improve everything. They’re going to use the Toyota production system or some other system. That leader is enthusiastic and supports the COO and others to start these programs, and the programs get going and are beginning to develop a culture of improvement and that culture is beginning to filter down into the organization. And the CEO, in the meantime, is concerned with increasing the size of the hospital system, developing new clinics, and so on.
Kornacki: Growth is a big priority.
Schein: Growth becomes the big priority, and so that person takes his eye off the ball of the internal improvement. I see this a lot. In that process, in the two cases that I have in mind, the growth process becomes dysfunctional. The amount of investment in growth begins to exceed the amount of income from increasing numbers of patients. After a couple of years, the board decides this growth has to be slowed down, and that CEO gets an offer for another job and they agree to part.
The CEO leaves and the new CEO comes in with partly the mandate of, get this thing under control. And guess what? The first thing that new CEO sees is how much money has been spent on creating a culture of improvement and begins to curb that and literally begins to fire some of the people who have created improvement programs that are costly and that are effective — but because they’re costly they get killed.
Now, suddenly, this new culture of improvement regresses. Everybody pulls back, a lot of people get laid off, and in a couple cases, some of the most important architects of improvement say, “I don’t want to work here anymore, my work isn’t valued.” They move themselves to another system, and the culture of hierarchy and cost control takes over because of this cycle. And where is the problem? The problem is that neither the board nor the earlier CEO built enough controls to ensure that the improvement culture, the level-two, more open culture, would survive their own departure.
What is most interesting in my acquaintanceship with Virginia Mason is that Gary Kaplan knew from the beginning that if he didn’t get his board on board, he would be vulnerable to the same process of at some point his leaving and a new CEO coming in and undoing all the good that he had done. The big lesson is, the top creates culture, and you therefore can’t change the top without worrying about what is the new top bringing in, the new board, the new CEO — they will change the culture, inevitably.
Kornacki: What I’m hearing you say is that the culture keepers need to be the board. In our industry, CEO turnover is quite high, and a CEO might be in an organization 2 to 3 years and then leave. If anything is going to be embedded in a more permanent way, members of the board really need to own to their responsibility in helping create and maintain a culture.
Schein: That’s absolutely correct, but there’s a footnote. The board is not going to figure that out for itself. The leader CEO, the Gary Kaplans of the world, have to educate that board. One of the most interesting things I learned from the Virginia Mason case is that when Kaplan took board members to Japan, the reason was [that] he wanted them to personally experience stuff, not just hear about it and be shown how great everything is. We think we educate the board by showing them results, but they don’t understand how the results were gotten, and so the CEO is the key.
[When] you get a CEO who’s an innovator, the biggest mistake they make is to start the process and not bother to educate either the board to or to keep their own eyes on the process itself to make sure that they themselves own it and don’t just hand it over to the COO or, even worse, hand it over to HR. That’s the worst thing when we march in and say, “We’re going to have an improvement program, and HR is going to administer it.” You know right off the bat it’s going to die —
Kornacki: The ownership at the top is lacking.
Schein: Let me tell you how that will happen. This idea of personizing and level two has to happen between the CEO and his immediate reports. If he or she doesn’t create level-two personized relationships with them, they won’t know how to pass it down through the line. And it’s not a staff function. It’s a line function. Every level has to recreate the personized level-two relationships.
Kornacki: I want to go into that a little more. I’ve heard you talk about something called “level one” and “minus one.” Can you go into a more detail about this “level two,” what you mean by that, and why it would be important?
Schein: Great question. That’s where the important new thinking has to happen. If you think about all societies, they differentiate levels of relationship that are considered normal in the society. The level of minus one is the level of where we dominate. That’s where the chief surgeon is a bastard who yells at his nurses and who dominates them.
Presumably there’s less of that today, but there was a period in history where domination by the leader was the norm and the subordinates swallowed it and took it. We see that in prisons and sweatshops and all kinds of functions. We’ve pretty much gotten rid of that in democracies, but we see pockets of it here and there, even in hospitals, I’m sure.
The next level, level one, is the traditional way we deal with strangers. In normal hierarchies and bureaucracies, they are defined by how we deal in normal transactional relationships between roles. The role of the doctor is prescribed, the role of the nurse, the role of the tech, the role of the patient. We know how those roles are supposed to work. We have created the concept of social distance, don’t let those roles get too close, and that has created a lot of the problems that we see.
Level two is when we get more personal and say, “It’s not just a role. It’s not just nurse X. It’s Mary Jones.” Maybe if I get to know Mary Jones and reduce that social distance a little bit, we might have a better working relationship. I might get to know that the reason Mary Jones sometimes is late for work is because her home situation is critical. For me to know that is not a disadvantage, but it’s an advantage in that we can then compensate for difficulties that she may have, or the day I am nervous as the surgeon, she will understand why maybe I am.
Personizing and getting to know each other within the context of the job is what I’m calling level two. We’re not going to be friends, we’re not going to go out together, but we’re going to know enough about each other to get past the formality of the role. It’s like my example of the doctor saying with a smile, “Look, let’s make these 10 minutes count. We’re both in this problem.”
Kornacki: Or what we might call team-building by going out and having a meal together, breaking bread.
Kornacki: It’s interesting, your focus on getting to people in this era of #MeToo. There’s the bit of a dilemma about how personal are you suggesting we get, when it’s easy to misinterpret signals or to be concerned about why is somebody asking these certain questions. Is there any guidance for that kind of getting to know you as a person within appropriate boundaries? Any thoughts about that?
Schein: Sure. The term “humility.” If you look at the #MeToo movement, the thing that has gotten the press is the sexual harassment. The point that’s missed is [that] what makes it harassment is a power move. It’s when someone exerts power over you, that you have this reaction of, “This is not appropriate,” and so the question of humility becomes the key.
When [Harvey] Weinstein exerts power over these young actresses, that’s what’s wrong. If he falls in love with one and she with him, that’s nature, but that’s not what the #MeToo movement is about. It’s not about romance. It’s about the use of power to gain sexual favors and put other people down. Power is lack of humility. What this coaching does, where hospitals will coach surgeons and doctors on how to be more human with patients and nurses, the coaching is about learning how to be more real and humble rather than being obsessed with the power you have.
Kornacki: Or the power associated with your role.
Schein: Or the power associated with the role. Personizing is equating power between people rather than getting too close. Level three is intimacy. Intimacy is not appropriate in a lot of work situations. And yet, we’ve discovered that in certain operations, like in the military, even maybe in the operating room, some things get so complicated that you want to know the other person at an even deeper level because you’re going to be in an immediate interdependency for that surgery to work.
We’re not ruling out that, occasionally, even the concept of intimate knowledge of how we work may be desirable. We’re arguing you have to get past level one into level two so that you can predict each other’s behavior, so you know each other well enough to be able to work on these more complicated, interdependent situations.
Kornacki: One of the difficulties is that if I’m the leader, I get that the organization is paying me. They’re paying me for my role. I’m the leader, and what you’re suggesting is that I create processes and support ways of other people, as you say, creating new ways to do things. Let’s call that leadership. Is that not threatening to someone who’s grown up with a paradigm about leadership being an activity that someone with a formal role is responsible to do?
Schein: It’s very threatening, but at the same time, as tasks become more complex, the person in that formal role will begin to realize that he or she doesn’t know enough to do it by themselves. What will really, in the end, create humble leadership is the recognition by the people in the[se] roles that they do need the help of their direct reports and their teammates and others.
Kornacki: People do carry a burden to think that it’s them, it’s about them fixing it, and that weighs people down when it’s not even true.
Schein: The young people who are coming into these roles are already much more ready for this. They’ve dealt with complexity and they know that complexity is best dealt with in a group process.
Kornacki: Let’s try to capture what you were saying earlier. You said it in a succinct, clear way about creating the process where others are allowed to come forward with the new way, the better way, the idea, the novel approach to a problem. That’s leadership.
Schein: Absolutely — because, again, of complexity. If you’re running an automated assembly line where everyone has a specific job that’s well defined and the boss knows exactly what his or her job is, the old system worked perfectly. The problem is that’s now how work today feels. Work today is interdependent, complex, perpetually changing.
So we’re arguing that the reason we need a new concept of leadership is not because the old concept has always been wrong, but [because] the world is changing and that the world of work is requiring new, more collaborative, multicultural, interdependent kinds of groups that have to be managed differently or they won’t function at all. It’s the work that’s changing the requirements for new kinds of leadership.
Kornacki: Right. I was in the taxi going to the airport with a young man who works for a software company in the Boston area. We were chatting, he had some association with MIT, and I said, “I was coming out to see you.” He was young, he didn’t connect to the name, but he said, “In my group, we have software people working, and our company is trying to hire someone who could be a facilitator of the people in the group.” I thought that was interesting, that now, given the nature of the work, rather than embedding leadership to do that, their default is they know there’s a need to pull these people together to collaborate in different ways and they’re looking for a group facilitator person to do that.
Schein: It’s sad that they’re thinking of that as facilitation rather than leadership. That will be the same as leadership. Facilitation is leadership.
Kornacki: When I look back, I think it’s been the lack of true appreciation and valuing of process, and I completely agree with you on that. That’s something that for very long has not been a big focus.
Schein: We have to redefine the word “process.” Process usually means the engineering process, which is fixed and standardized, and we’re talking about group dynamics and interpersonal processes. That’s what people are uncomfortable with, and that’s why I think a word like “personizing” and having other words [like] “facilitation,” “being a catalyst” [is important]. The word “leadership” itself should die and we should start using the words “convene”, “direct,” “facilitate,” “order.”
There are all these other words that are part of what we think of as leadership, but they are all different in different situations, and so we should be more precise. Is the surgeon starting the big open-heart surgery? Is he the boss, the director, the facilitator, the expert? What’s the essence of that role, and thereby what are the essences of the other roles? It’s not about leadership. It’s about a much subtler differentiated set of things that the people are doing that we end up calling “teamwork,” but teamwork is also too vague. What kind of interdependence are we talking about?
Kornacki: Going back full circle to where we started, the world is fast changing, fast moving, complex, and you’re making a case for level-two relationships in those situations.
Schein: Correct. When those situations begin to work in team A and each member of that team begins to work level-two personizing with his other relationships and with direct reports, that’s how you gradually build a culture of level two. Most people, when they work at that level, say, “This is much more fun. I feel more relaxed.” One of the most dramatic statements I heard a chief of medicine say is that doctor burnout is much less for doctors who have a more personal relationship with their patient than for doctors who have a level-one distant relationship with their patient. Closeness is easier on the psyche in a certain way.
Kornacki: This has been fantastic. I want to think you for taking the time to share your thoughts with us. It’s been quite an honor to be with you.
Schein: Thank you. I’ve had a good time expressing these thoughts. I do believe that this personizing and levels of relationship are key to the future.
Read or listen to Part 1 of this interview.
This conversation was recorded live at Stanford in Palo Alto, California, in March 2018, by Mary Jane Kornacki on behalf of NEJM Catalyst. Click here for more Lessons in Leadership stories.