John P. Kotter in his 2014 book Accelerate notes that “[Leadership is] not about mobilizing a group to act the same way they have always acted. It has to do with changing people and their organizations so they can leap into a different and better future, no matter the threats or barriers or shifting circumstances.” These twin responsibilities—establishing a vision to inspire staff to bring their best talents and expertise to the work and providing the enabling environment for that vision to be realized—are essential for every leader.
So, how do leaders both inspire and enable transformational change to improve patient care and experience in partnership with those who are responsible for operationalizing and managing changes to operational and clinical processes? How can leaders identify and prioritize the adaptations that might be needed for specific contexts? The answer lies with “active listening,” which is a total focus on the other speaker that allows no mental space to parallel process a response or prepare one’s thoughts to start talking. When done well, it encourages even more feedback. Active listening enables leaders to develop and learn from genuine partnerships with staff, gain the knowledge needed to co-design solutions, relieve bottlenecks and build momentum where progress already exists.
Interpreting body language and subtext is an important aspect of active listening. Nonverbal communication conveys volumes about sentiments and concerns. Active listening also means refraining from interruptions, which influence the perception of your receptivity to the feedback and might therefore influence the feedback itself. Given the power dynamics in organizational hierarchies, leaders must be genuinely open and receptive to feedback, both positive and negative, to gain a system-level understanding of what is and is not working, as well as a granular understanding of what’s happening at the front lines of delivering care to patients and their families and caregivers.
This practice can be described in five phases, loosely referred to as the leadership-listening arc: Curiosity, Learning, Alignment, Negotiation and Creativity. Each phase can help leaders achieve the dual goals of inspiring and enabling change in true partnership with clinicians and operational staff in service of providing high-quality patient care.
1. Curiosity
Don Berwick, MD, the founding CEO of the Institute for Healthcare Improvement, emphasizes that without genuine curiosity there can be no genuine learning. Curiosity generates questions in the listener and focuses attention on the ongoing conversation while avoiding assumptions about what the other person(s) might be thinking. Real curiosity requires recognizing that we will never know the full breadth and depth of another person’s thoughts and feelings, no matter how well we know them. It also requires being humble about the limits of one’s own expertise and experience. This humility sharpens curiosity about how the change initiative may be affecting different groups and processes within the organization.2. Learning
Staying genuinely curious and truly working to understand what the other person(s) says often leads to learning something new. It might be a major insight that upends our thinking, an important nuance not yet fully appreciated or even new evidence confirming something we already knew. Regardless of the outcome, when we try to learn as much as possible from our colleagues, we honor their time, experience and expertise. We also demonstrate a willingness to listen and learn about what is and what could be instead of merely what should be.3. Alignment
Sometimes, resistance to organizational change stems from misalignment or a misunderstanding of the changes needed. The leader may be thinking of a change conceptually, while those providing feedback are thinking about the challenges of practically applying the change in their contexts. It is essential to align these two different levels of thinking to include both considerations. Understanding the relevant change conceptually (i.e., as a general notion or approach to change) may help staff develop new ideas that align with the ultimate transformation desired. Considering the impact of the change at the practical level reinforces the leader’s commitment to co-designing with staff and relieving bottlenecks. Combining and aligning perspectives will reduce hurdles in the change management process and increase the likelihood of greater impact.4. Negotiation
In the event of genuine disagreement about the expected benefits and risks associated with a proposed process change or system redesign process, leaders need to shift the benefit/risk ratio in favor of benefits to make a more convincing case. They can also negotiate on timelines, milestones and resources needed, for example, adding more staff to the team responsible for implementing the change, or pausing other initiatives to create more time and space for the current change effort. Delaying launch by a few weeks or months may give staff the time needed to be more creative and deliver a reliable product or service. Leaders could also use a phased approach to implementing the change—with agreed-upon pauses for reflection and learning—to create opportunities for productive negotiation and ultimate alignment.5. Creativity
If the proposed change proves to be inoperable within existing systems and processes, too expensive, too labor-intensive or not as good a fit for patients as initially envisioned, new ideas will be needed. When leaders create enough psychological safety, and have proven to be genuine partners to front-line staff and middle managers, the feedback conversations can produce these new ideas and adaptations. Challenging the status quo and diverging from mainstream problem-solving paths prompt creativity, help avoid mental ruts and foster transformational improvement ideas. In his 1992 book, Serious Creativity, Edward de Bono, an authority on creative thinking, describes this as, “exploring multiple possibilities and approaches instead of pursuing a single approach.” Engaging staff in a creative exercise has multiple benefits. The obvious one is generating new ideas that weren’t considered before. Another is that such exercises demonstrate a distributed leadership philosophy that empowers staff at all levels and creates a sense of shared ownership in the change and, ideally, in the long-term success of the organization.These five phases can be pursued in sequence or in parallel, depending on the flow of the conversation and what leaders learn along the way. The time frame for the phases of the leadership listening arc can be as long or as short as needed based on the leader’s context. The key is the effective practice of active listening in all phases. As with all practices, repetition and discipline lead to improvement over time. A leader who wants to achieve the vision they have set out by effectively partnering with staff needs to become an expert active listener.
Nana A.Y. Twum-Danso, MD, FACPM, is senior vice president, Institute for Healthcare Improvement (ntwumdanso@ihi.org).