Innovative leadership is the driving force behind cultural transformation.  Organizational change is fostered in an atmosphere of trust and realized over time.  Essential to successful, innovative structural change are interpersonal leadership skills which are flexible yet consistent.  Change operates from the "bottom-up," as well as from the "top- down."  These are the conclusions of Barriere, Anson, Ording and Rogers in their case study of an 1,800-employee, cardiac hospital in metropolitan New York, which transitioned from a stable, bureaucratic institution to a "highly-adaptive, world-class" cardiac center.

 [Barriere, M. T., Anson, B. R., Ording, R. S., & Rogers, E. (2002). Culture Transformation in a Health Care Organization: A Process for Building Adaptive Capabilities Through Leadership Development. Consulting Psychology Joural: Practice and Research, 54(2), 116-130.]

The authors, who were the external agents (consultants) for change at the hospital, noted that details of the transformation process are often lacking in the literature.  Thus, their purpose was to provide details of the change process, which involved "designing, implementing and evaluating a leadership development intervention" to set the hospital on a more adaptive, innovative course.  The hospital's challenge during this four-year initiative was to stay competitive and maintain patient-care and regulatory compliance standards.   

 Change Shift

The change mandate came from the hospital's chief executive officer (CEO) and human resources vice president, who realized that to maintain the hospital's leadership position in an increasingly competitive environment, would take more involvement and innovation by the lower-levels of the workforce. This shift to leading change from down-up was a dramatic departure in the hospital culture, the authors noted.  

 Three key steps were determined necessary to foster a workable cultural transformation:

1. delineating organizational priorities in a changing health care industry;
2. assessing the existing hospital culture;
3. designing, implementing and evaluating interventions aligned with priorities that create and continue "an innovative and adaptive culture."

Senior-level focus groups facilitated by the outside consultants were formed initially to establish organizational priorities. Through the focus groups, senior executives determined that mid-level management help would be key in driving innovation and communicating with subordinates. This led to one of the highest hospital priorities: ensuring that management possessed the leadership skills to acquire an adaptive culture. Once this priority was established, the hospital developed and implemented a two-part leadership training program: Leadership I, which focused on individual leadership skill development and performance; and Leadership II, which was designed to encourage and foster cross-department communication and support.

Prior to the leadership training programs, Barriere et al utilized the Litwin Stringer Climate Inventory (Litwin & Stringer, 1968) and other less formal input to assess the strengths and weaknesses of the existing work culture and to gather suggestions for improvement.  Feedback was received from about 20% of the hospital's employees, who were divided into four tiers for the inventory:

• Tier 1 - - senior management (VP through CEO);
• Tier 2 - - management reporting to senior management (assistant VPs through  division heads);
• Tier 3 - - line managers;
• Tier 4 - - all other non-managerial staff.

These tiers were randomly sampled and asked to evaluate six organizational categories:  structure; standards; responsibility; recognition; support; and commitment. 

 The overall Litwin inventory results showed that:

1. employees across all tiers rated organizational commitment and structure most positively (82% and 76%               respectively);
2. considerable deviance was noted between Tier 1 and other Tiers in the responsibility category (more than 60% positive responses from Tier 1 vs. less than 25% positive responses from Tiers 2,3 and 4);
3. low scores for recognition (41%) were reported by Tier 4;
4. discrepancies between the tiers were noted  with regard to support from and standards being exhibited by supervisors.
   

The lower scores with regard to responsibility dealt with employees feeling they had little autonomy to act/think independently, or encouragement to assume responsibility.  The low recognition scores were interpreted as insufficient recognition for accomplishments.  An additional, open-ended response survey supported the conclusion that while organizational structure and staff commitment were highly rated, improvement was needed in areas of communication, teamwork, individual initiative and innovation.   These employee climate survey results provided the baseline data for the Leadership I and II's program development, structure and goals.

Three questions, derived from the hospital-wide, employee climate surveys, guided the structure of the Leadership I program. The first asked which aspects of leadership culture most needed to be improved.   The second question involved an investigation of the practices currently used by the hospital's "best" leaders. And third, what behaviors would the best future leaders need to exhibit.  Five leadership themes emerged from these guiding questions: 

• communication skills
• motivation and feedback
• staff participation in goal setting
• individual challenges
• Teamwork

Using the questions, leadership themes, and the climate surveys, the consultants devised a "leadership placemat" or rubric which consolidated "33 critical leadership practices" into six categories: 

• communicating organizational values
• encouraging initiative by individuals
• constructive coaching and feedback
• the creation of a climate of trust
• personal leadership
• "leveraging the entire hospital team" (community building)

Table 1: LEADERSHIP PRACTICES PLACEMAT
I. Hospital Values Communication	II. Encouraging Individual Initiative	III. Constructive Feedback & Coaching	IV. Creating Atmosphere of Openness & Trust	V. Demonstrating Effective Leadership	VI. Leveraging the Entire Team
l. Effectively balancing the hospital's business and patient case priorities	7. Clarifying responsibilies within the group	12. Giving feedback on job performance	18. Conducting meetings in ways that build trust and respect	23. Selecting and promoting the best people	28. Putting hospital objectives ahead of personal, unit, or departmental ones
2. Communicating high personal standards of compassionate care	8. Encouraging people to initiate tasks or projects thought important	13. Providing fair and even-handed feedback	19. Behaving in a way that encourages trust	24. Managing change in thoughtful and well-planned ways rather than reactive	29. Collaborating effectively with others
3. Setting challenging performance goals and standards	9. Encouraging people to find and correct their own mistakes	14. Recognizing good performance more than criticizing mistakes	20. Encouraging an open exchange of ideas and different points of view	25. Focusing time and energy on most important priorities	30. Encouraging shared ideas and information with others
4.  Treating employees fairly	10.  Encouraging and rewarding innovation and new approaches	15. Being supportive and helpful on a daily basis	21. Listening to others	26. Being a person who delivers what is promised	31. Understanding which decisions can be made alone and which need to involve others
5. Demonstrating personal concern for success of employees	11. Empowering people to deliver high quality care	16. Going to bat for people with your manager when you feel they are right	22. Responding in a nondefensive way when others disagree with you	27. Acknowledging one's own mistakes and limitations	32. Recognizing value of diverse per-spectives and opinions
6. Pushing people to look for new ways of saving money, increasing productivity and improving quality		17. Spending time to coach effectively			33. "Reaching out" to help people in other departments

The Leadership 1 program used the 33 leadership practices identified in the leadership placemat as their change agenda for management, and encouraged management to use the collected data to determine which leadership practices needed improvement and which leadership skills needed to be developed.  To support which leadership practices needed improvement, feedback was solicited from a representative sample from each manager's subordinates.  Following stringent collection and interpretation guidelines for these feedback results, a two-day workshop was provided by consultants to:

1. help managers interpret the feedback results and determine development needs and action plans;
2. provide training and coaching to management in the identified leadership skills that needed improvement.

Following the completion of Leadership I training, management provided feedback on the strengths and weaknesses of the organizational structure pre- and post-training.  Two new priorities to facilitate cultural and organizational change emerged:

• the need to develop models for constructive feedback and coaching, and;
• the need to facilitate teamwork and a sense of community across departments. 

With these guiding priorities, the Leadership II program was developed and implemented. Leadership II provided additional coaching and the setting of goals and action plans by the individual managers.  The rubric developed in Leadership I was again employed and progress on the six leadership categories was monitored over time.  Overall, there was statistically significant progress made in all 33 subsets over the two year time frame measured.

Results 

Overall, there was statistically significant progress made in the 33 subsets.  Over a two year time frame measured between the beginning of each leadership program there ws improvement noted in all leadership skills including a 10% increase in percentile rank in 22 of the 33 practices.  All areas noted as weaknesses in Leadership 1 showed a 10% increase or better in percentile rank.  

The approach taken by the hospital was influenced by and consistent with Harvard Professor John Kotter's change model, which involves relying on leaders from all levels of an organization to inspire cultural transformation. The same population of managers participated in both leadership programs in a similar top-down approach.  The leadership development handbook For Your Improvement by M. Lombardo and R. W. Eichinger, was supplied to all managers as part of the Leadership II program.  The consultants coached management in developing action plans for their leadership development based on the recommendations outlined in the handbook.  The authors contend that it is those sorts of "soft science" leadership skills, which when transferred across the employment tiers that are the essence of effective, adaptive and innovative cultural change.

The consultants, through their expertise and the use of objective data from the climate surveys, focused on building trust and support for change across management tiers, which was vital to the success of this culture transformation.

In conclusion, when managers were given the opportunity to develop and practice exemplary leadership behaviors, these "best practices" became the underpinnings for cultural transformation.  At the conclusion of this four-year project, the Leadership Practices Placemat was incorporated into each employees' yearly evaluation and training.  Managers solicited input from their subordinates in developing goals and action plans, and a new performance assessment tool was developed for both managers and subordinates to receive objective, meaningful feedback. Essential to meaningful organizational change, the authors note, are the necessity of results being measured over time, the clear communication of the organizational vision to all stake-holders, and the roles individuals, both "at the top" and "on the bottom," play in promoting and propagating cultural change within organizations.

Tools/Knowledge Objects/Resources/Contacts/Etc:

 Resources:

• Kotter, J. (1996).  Leading change. Boston: Harvard Business School Press.
• Lombardo, M. M., & Eichinger, R. W. (1996).  For Your Improvement : A development and coaching guide. New York: Lominger Limited.
•  Litwin, G. H., & Stringer, R. A. (1968) Motivation & Organizational Climate. Boston: Harvard University Press.
• Dalton, M. (1996). Multirater feedback and conditions for change. Consulting Psychology Journal: Practice and Research, 48, 12-16.
• Michael T. Barriere last found email address: psymthb@hofstra.edu. 

 

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