Practice Management

Advancing coherence: Your “meta-leadership” objective

Learn to balance organizational priorities


For the many people who expect you to lead, your role – among others – is to create coherence. That coherence characterizes the logic and consistency of what you do in your organization. It assembles the individual work of many different people into a whole that functions well. Coherence in your workplace helps people make sense of what they are doing and why it matters.

Leonard J. Marcus, PhD, director of the program for health care negotiation and conflict resolution, Harvard T.H. Chan School of Public Health.

Leonard J. Marcus, PhD

Our very rational brain craves coherence. We assemble facts, emotions, ambitions and our life stories into narratives that define who we are, what we are doing, and why it is important. An effective organizational “metaleader” encourages that process for followers. It helps people make sense of the work side of their life.

When coherence is absent, the workplace is riddled with contradictions, unpredictability, and dissonance. People are expected to accomplish tasks for which the time, tools, and talent are missing. There is a perplexed swirl of high activity and low productivity. Expectations for high quality of care and patient satisfaction are contradicted by an overbearing workload, reams of paper work, and the low morale that leaves the work force lethargic. “What we are doing here and how we are doing it doesn’t make sense,” exemplifies the exasperation of working amid incoherence. The department does not drive together toward success-oriented performance. Instead, different people, priorities, and opportunities will be positioned in conflict with one another. For people in your group and those surrounding it, morale and motivation suffer. There is the risk that people will descend into malaise.

Creating coherence is a complex metaleadership process. A large health care center is a cacophony of priorities, of which advancing quality of care is but one. There are other objectives, some contradictory, that also absorb time and attention: achievement of financial benchmarks, promotion of professional careers, and the individual hopes and desires of patients. Systematically aligning those many priorities and objectives is a process of both design and leadership.

The metaleadership model is a strategy for building coherence amid the complexity of health care operations. For those unfamiliar with metaleadership: The prefix “meta-” refers to a wider perspective on what is happening, the people involved, and the overall combination of objectives. The three dimensions of practice are: 1) the Person of the metaleader – your own priorities, values and emotional intelligence; 2) the Situation – what is happening and what ought to be done about it; and 3) Connectivity of Effort, which leads down to subordinates, up to bosses, across to other internal departments, and beyond to external organizations and professionals.

In building connectivity of effort, the metaleader links the many sides of the work being accomplished. The intent is to balance – purposefully – different organizational objectives into a combined whole that gets the jobs done. Furthermore, that coherence links and adapts what people are doing to the situation at hand. And in essence, the person of the leader cannot lead broader coherence if not coherent in her or his own thinking, attitudes, and behaviors, so achievement of personal and professional clarity of purpose is important.

The question for you: How do you as a hospitalist leader create coherence in what you are leading given the changing priorities, actions, and turbulence of current health policy and the market?

The answers lie in the communication you foster and clarify. That communication demands clarity and diplomacy. It is multidirectional such that messages and information in your leading down, up, across, and beyond complement and inform one another.

An illustration of one pathway: You learn from senior management about cuts in the budget. You reflect with them on the choices implicit in those cuts. Perhaps there are better ways to reduce expenditures and increase revenues that offer an alternative pathway to a balanced budget? When communicating with your subordinates, you open conversation on ways to enhance efficiencies and assure quality. You explore avenues to partner with other departments within your institution on how you can link and leverage services and capabilities. And you consider your marketplace and the actions you can take to reinforce your department and assure the volume necessary to achieve budget and quality objectives. And through it all, you monitor the situation. What are the effects of the budget adjustments, and what can be done to sustain the coherence of the work and output of the department? It is a leadership process of constant situational awareness, personal commitment, and connectivity of effort.

An illustration of another pathway: Resist the change and argue forcefully for holding onto the current budget and workforce. Though you do not possess the authority to control larger budgetary decisions, you employ influence well beyond your authority. You recruit allies to your cause, advocates who believe in the purpose you are promoting. You build an alternative coherence, mindful of fostering friendship and minimizing alienation. You are recognized for the passion of your professional commitment and your capacity to uphold quality care and organizational balance.

Two very different pathways to crafting coherence. Leaders of each perceive their actions to advance priority coherence objectives. Apply this question to your own complex problem solving.

Metaleaders forge coherence through the narratives they build and the consistency with those themes and priorities. When everyone on your staff, from physicians to housekeeping personnel, can say “I am here to help save lives,” you know that your followers are on board with a shared mission. They recognize that their efforts contribute to that overall mission. Each person has a role to play, and her or his work fits with the efforts of others, and the bottom line accomplishments of the department.

The coherence you forge assists your followers to make sense of what they are doing and how it fits what others are doing. Work is fulfilling. Beyond that, in a turbulent health care system, you anticipate both problems and opportunities with strategies to meet them. You stay ahead of the game to ensure that people within and outside the department are aligned to maximize opportunities for success.

This is particularly important for the hospitalist. Your job is to fashion coherence on many levels. First, coherent patient care for the patient. Second, coherent interactions among professionals. Finally, organizational coherence, so one piece of the puzzle fits with others. And, when there is a need to recalculate, you adapt and develop solutions that fit the people and situation at hand.

Dr. Marcus is coauthor of Renegotiating Health Care: Resolving Conflict to Build Collaboration, Second Edition (San Francisco: Jossey-Bass Publishers, 2011) and is Director of the Program for Health Care Negotiation and Conflict Resolution, Harvard T.H. Chan School of Public Health, Boston. Dr. Marcus teaches regularly in the SHM Leadership Academy. He can be reached at [email protected].

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