Leading Coalitions

# LEADING COALITIONS > Jim Reinertsen, on behalf of the Institute for Healthcare Improvement, ask me to prepare some thoughts on leading coalitions from our learnings in Whatcom County's Pursuing Perfection work.

**A Personal Reflection** _A few observations from Whatcom County, Washington. Presented in person on Wednesday, April 30, 2003._ Leading community coalitions is about shared values--creating, or more likely, unearthing and polishing them. First, I disclaim: I don't know. We are improvising. In fact, the key is probably improvisation. Second, a recommendation: find at least one person that is or will become consumed by the opportunities. Next, here are ten ideas we seem to be using in Whatcom County Washington as we pursue perfection in health care delivery across a community.

# 1. Bring the outside in. Don't assimilate it. Protect it. Pay the money. Don't expect double duty. Trust is the key. Find those known to be "pure of heart" and help them stay that way. If you have this role (outside brought in) understand that the relationship with the outside is the key value on the inside. Invite the Trojan horse in. Don't lose the affiliation and affection. You are looking for someone who represents the positive values that you share with the community and who understands the conflicting values.

# 2. Hire and empower successful revolutionaries as leaders. Transformation is a kind of revolution. They must want and see the new way more and clearer than you do. You must support and protect them. Trust them. Trust your job to them--to the cause. Be willing to be overthrown if necessary (but try to keep up with the revolution--the loss of your job probably helps no one except your successor.) Ask your team and others in the coalition about their credentials as revolutionaries. Encourage a radically transformative stance. Model it. Be irreverent. We have wonderful revolutionaries. We have people with years of successful experience with coalition building.

# 3. Become a story junky. Find the right stories, tell them, get others tell them. Make them up if necessary. Stories around campfires have created and sustained tribes and communities for thousands of years--long before Excel and PowerPoint. We are built to create meaning from stories. Stories go to the heart and heart is what is needed for transformation. Become the story you need. Make sense, create new meaning with stories. From the chaos of "facts" pull out the relevance you need and storify it. This is the job of a leader.

# 4. Revert to common values. Technique will not work here (yet?). Explore values all the time. Talk about values. Tell stories about values. Hire strong value-based leaders and staff for this work. Values trump power (status quo). You must ensure this.

# 5. Make it up as you go. Karl Weick talks about bricolage, a French word that does not translate well. A bricoleur is a person that can routinely make what they need from what is at hand. They can make a uniquely useful machine from spare parts in a barn and it may do the job better than anything on the market. Gather all the bricoleurs you can find for this kind of work. >Bricolage--A form of improvisation practiced by some, using whatever resources and repertoire come to hand, in order to perform the immediate task. A person who practices bricolage is called a bricoleur. In a paper called, Organizational Redesign as Improvisation, Karl Weick identifies the following requirements for successful bricolage. - intimate knowledge of resources - careful observation and listening - trusting one's ideas - self-correcting structures, with feedback Improvisation is a related idea. Quite different than "experimentation". Think of the "improvisational organization" as a variant on the "learning organization." More real time, more masterful. That is what is needed. For an in depth understanding of this concept and also a related exploration of "wisdom as improvisation " see this article: The Attitude of Wisdom: Ambivalence as the Optimal Compromise, Karl E. Weick.

# 6. "Appreciative Engagement" I have coined this term to combine two profound yet simple ideas. "**Appreciative**" points to a stance and techniques that are well explained by David Cooperrider of Case Western Reserve and Gervase Bushe of Simon Fraser University as well as others. The idea simply stated is—look for what you appreciate and want to see more of instead of focusing first on what you don't like and want to see less of. "**Engagement**" points to Axelrod's thesis that many of the problems of change can be avoided by investing in the engagement of all the folks who will have to implement or change—up front, at the beginning of the exploration. Pay, listen, and engage now to avoid failure in the implementation phase.

# 7. Systems thinking must trump liner, simplistic planning. Complex adaptive systems (CAS) are a useful way to think about health care, especially across organizations—coalitions.

Paul Plsek's Appendix B in the Chasm Report is the most important part of the book. The challenge put forth in the book is to create a coherent system that will dramatically reduce the burden of illness in the citizens of this nation. Success is impossible without understanding the way complex, adaptive systems work. Rules for optimizing a CAS: 1. Agreement upon **clear aims** (patient-centered, safe, equitable, etc.) 2. Follow **a few simple rules** (cooperation, relationship, transparency, etc.) 3. Ensure effective **communication among** the agents/parts 4. Provide opportunities and resources for **experiments** (fertilizing and watering) 5. **Pruning** (removing resources from experiments that fail to move the system closer to the aims) 6. Explicitly **model the system** for policy making. > Robert Wood Johnson Foundation paid for the modeling of Congestive Heart Failure and Diabetes care in Whatcom County. The understanding of the local health care system's dynamics is already helping our key stakeholders to come together with aligned incentives. I have never seen anything like this before.

# 8. Get committed. Karl Weick gives a useful operational definition of commitment. I am probably paraphrasing but my memory of it is: 1) personal, 2) voluntary, 3) public, and 4) irrevocable statement of intentions and agreements. In a coalition, don't assume you have commitment without having all parts of this formula for each key stakeholder and leader. Get boards, CEOs, opinion leaders, and front line staff to tell their stories in a way that fulfill these criteria. Model it yourself and invite others.

# 9. It's about LOVE, FAITH, and FORGIVENESS. The fuel for transformation is passion and freedom. Only love of others and self will get you through the maze and confusion. It is the beacon and fundamental value. Generate your faith that others will find their love and their forgiveness and that you will continually rediscover yours. Generate your faith that something great will result even if it is not what you anticipated. Generate your faith that transformation will come from clear and agreed upon aims with a few simple rules all of which are guided by love and forgiveness. Forgiveness of self and others is the moment-by-moment skill and key competency for transformation. Pursuing perfection is not about punishing self or others for lack of perfection. We are all so hard on ourselves and others that we create an unbearable burden. Drop it. Again and again.

# 10. Give away (through stories) all the success. Take responsibility for all the screw ups. There will be plenty.


MY REQUEST--please invite new IHI faculty, specifically: 1. Karl E. Weick (Sensemaking and High Reliability Organizations) 2. David Cooperrider and Gervase Bushe (Appreciative Inquiry and Clear Leadership) 3. David Snowden (Cynefin Model and Cynefin Centre) 4. Jack Homer and Gary Hirsch (Group System Dynamics Modeling and Simulation for cross-organizational, cross-industry policy making.)

Author: Marc Pierson, marpie1@comcast.net. Protected by Community Commons— Attribution-ShareAlike 4.0 International (CC BY-SA 4.0).