"Generative" Health Care Leadership, Governance and Boards of Directors

Time to get "generative!"

Thanks to bout of troublesome weather, the Population Health Blog has been stranded somewhere in the U.S. air-travel network. Undaunted by bitter loss of an upgrade and the prospect of a late arrival, it bravely used the down time to dig into the highly interesting book Governance as Leadership: Reframing the Work of Nonprofit Boards by Richard P. Chait, William Ryan, and Barbara Taylor.

While written for "nonprofit board members," the PHB believes the insights are applicable to just about any board of directors or other leadership group of an organization that is grappling with uncertainty. And given the uncertainty in health care, Governance is "must" reading for the leadership as well as the board of any hospital, physician-group, health system or provider organization.

Pointing to years of academic research, consulting experience and common sense, the book describes three "modes" of governance:

1. Type I Fiduciary, which relies on process and uses standing committees to ask (for example) if assets are being effectively deployed.  Think "data."

2. Type II Strategic, which relies on content and uses ad hoc committees to ask (for example) how strengths align with future opportunities.  Think "information."

3. Type III Generative, which relies on "cues," "framing" and "narratives" to ask less about the solution and more about the problem.  Think "insight."  
  
Boards are naturally inclined toward Type I and II governance. According to the authors, that's a mistake that can foster zero-sum thinking and the triumph of personal influence over group meaning.

Instead, when all three types are used at the right time for the right issues, they become synergistic and can create a tangible competitive advantage for the organization.  The best time to turn to Type III governance is when there is an issue that is ambiguous, salient, high stakes, contentious and irreversible.  The authors compellingly describe how present "cues and clues," can be used to "reframe" facts into new patterns.  As a result, the past can be re-narrated to imagine a new future.

Governance uses the example of the compelling insight that broken windows isn't the result of, but can lead to high crime rates.  That, in turn, led to the creation of "community policing."  The PHB would offer the health industry insight that the "problem" wasn't getting physicians to better care for persons with diabetes, but getting persons with diabetes to be better engaged in self-care.

You get the idea.

 The authors readily admit that Type III Governance is a "wilderness" that is an "outside-the" or "black" box that is non-linear, vague and subjective.

It seeks "sense" or meaning and creates multiple choices, not a single fix.  It generates insight and creativity, not mission setting, strategy development or problem solving.  It gets you to the drawing board.  It frames the problem.  It generates the hypothesis. 

And when reality is recreated, it can ultimately achieve a far richer level of down-stream buy-in.

How can Type III Governance be leveraged?

First of all, governing boards and their management teams must collaborate in this.  Boards have a particular role to play because they have the three "P's" of power, a plurality of multiple perspectives and a position of a more distant ("10,000 foot") vantage point.  Boards can work with their management teams by either acting as 1) sounding boards that foster generative thinking by asking, probing and identifying the cues, framing the data and renarrating the past or by 2) initiating generative thinking by focusing on ambiguous or problematic issues among themselves and their colleagues.

Be prepared to tackle sensitive subjects and dealing with multiple perspectives that is less about fixed unanimity and more about the sense of a "collective mind". Resist succumbing to notions or fostering groupthink.

Use retrospective questioning (to discover unknown strengths, flaws and patterns in the past) and dominant narratives (that create a meaningful bridge from the past to a portray a desired future) to gain greater understanding.

Embrace the generative mode early on the "elephants in the room." A otherwise unaddressed "big issue" will evolve over time and default processes and solutions will recast the situation as a planning or strategic challenge.

Use mindful deliberation without formality or rank that focuses less on creating the solution than on defining the problem.

To increase the chance of success, boards need regular exposure to inside-facing culture of the organization as well its outward-facing environment. That means having unfiltered access to the cues/clues inside (the "factory floor") and outside (with customers or other stakeholders). While there is a risk of board members or senior leaders running amok over established lines of authority, the risk to any organization is ultimately greater if they're confined to the boardroom or the C-suite. 

Generative thinking will feel more like "play" or a "retreat" than a meeting.  That's good.

Use tools like

Counterfactuals: What is it about the budget or the assigned FTEs that explains our goals?
Hypotheticals: If the company ceased to exist, where would its customers go?
Intuition: Is there a hunch about the next five years?
Catalytic questioning: Is there a headline we'd like to see?

Governance makes for interesting as well as fun reading. The authors avoid complex jargon and sprinkle their text with some insightful examples. While readers may struggle with the details of installing "generative" thinking into their leadership "workflows," the idea of using this template to harness the creative juices of a leadership group or a board is exciting stuff.