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  1. Porter-O'Grady, Tim DM, EdD, ScD(h), APRN, FAAN, FACCWS

Article Content

Healthcare and its services are changing in form and content at a rapid rate. As leaders, we need to be able to anticipate, predict, and guide adaptation to a large number of just-in-time changes and transformations. Predictive and adaptive skills are now a fundamental leadership mainstay. Understanding the elements of predictive and adaptive capacity expands our essential knowledge foundation and helps us develop contemporary skills that assist organizations in sustaining success.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

Managers deal with the challenges of change every day. Some scholars suggest that the one constant in the role of the manager is the ability to help others understand, cope with, and implement change.1 But what of the manager? How does this individual come to perceive, understand, and translate erratic changes into the life of the workplace and the roles of its members? Certainly, managers deal with change, but they also need to understand what change is occurring, when it occurs, its relevance, and its impact on the organization. The skill associated with this talent is identified as predictive and adaptive capacity.2


Now is the future

Predictive capacity is identified as the set of skills associated with imagining the future from the perspective of the present.3 Great leaders clearly understand that the future is constantly unfolding and the seeds of understanding it are embedded in what's occurring right now. There are a number of skills associated with predictive capacity. Each one is critical to constructing a view of the future that aligns with the substantive action of a host of forces that are coalescing to help bring the leader an indication of the trajectory guiding organizations, systems, and society into their collective future.


Boundary scanning

One of the essential skills in predictive capacity is the ability to look at the periphery of the world in which an organization lives. This ability to view the big picture helps leaders understand the characteristics that influence or impact the life of the organization from the outside looking in. No organization exists in isolation; each one in some way reflects the characteristics of the environment in which it's a part. This environment is composed of a number of elements that converge to create forces that influence and drive an organization's response, and impact its lived experience. Organizations are in many ways a microcosm of the larger society of which they're a part. If leaders want to understand the future of the organization, they must understand what's going on in the broader environment and how it influences or sets the trajectory of the organization long before the impact of external events creates reactive changes inside the organization.


The organization tries to align its internal mechanisms to positively respond to shifting societal forces. This constant interplay between external influencing forces and internal organizational responses creates the essential "dance" between the organization and the outside forces. (See Figure 1.) In the case of healthcare systems, their focus is the health of society and response to the demand society creates for addressing its healthcare needs. If the vitality of the organization is to remain vibrant, it must successfully fulfill its purpose and best meet the health demands of the community it serves.


Failing to do so creates a vacuum in the trust and relevance between the larger society, service users, and the healthcare facility. The life of the organization is threatened when society fails to obtain expected value from it or fails to believe that the organization will continue to act in its best interests. Therefore, society expects its healthcare organizations to be current and contemporary, to reflect the cutting edge of knowledge, anticipate need, and to translate new knowledge into skills and actions that positively impact the health of those who use its services.

Figure 1:. Predictiv... - Click to enlarge in new windowFigure 1:. Predictive elements of environmental shifts

Effectively using boundary scanning requires that leaders develop three specific skills:


1. Reading broadly. The skilled predictive leader reflects on a wide range of references and information about what's happening in the broader environment. Reading political, social, economic, and technologic literature provides a solid and broad database from which the leader can draw and translate into implications and actions in his or her own arena of accountability. Critical to the leader's understanding of environmental influences is the comprehension that sociopolitical, economic, and technologic forces are the three key drivers that influence all organized human behavior. Changes in each one of them, when converged to create significant changes in all of them, have a particularly positive impact on facilitating organizational change and innovation.


2. Translation. The potential to incorporate the environmental forces affecting an organization has no value if those forces can't be adequately translated into comprehensive language that everyone can understand. Leaders must be able to assess (from the broad sociopolitical, economic, and technologic forces impacting the organization) implications specific to the healthcare system and any related arena of practice. The ability to enumerate the confluence of external forces on internal organizational life and action reflects the successful use of predictive skills. This requires not only a clear understanding of the impact of external forces, but also the ability to "language" these forces and communicate them in a way that can be heard and understood by those who must implement them. Translation skills include the ability to simplify concepts, create a direct relationship between the forces and their specific impact on the roles and lives of individuals, and the ability to clarify what short- and long-term adjustments and accommodation to these external forces must be made by every individual inside the organization.


3. Personalization. It's not only important for leaders to translate change, but also to address it in terms that represent personal response to demand. Organizations are nothing if they aren't a collection of individuals committed to a common purpose and the necessary action that advances it. Therefore, leaders must be able to engage members of the organization at a personal level so they can see the impact change has on them and on their roles. Leaders understand that if individuals can better comprehend the why of change and action, they're more willing to embrace the how of it. Leaders then engage the stakeholders in a meaningful dialogue as a way of translating the impending change and also clarifying the specific response and action for which individuals will be accountable.



Predictive tools

Examination, descriptive application, and effective decision models are examples of tools used to ensure the close relationship between strategic direction and personal action. Increasingly, health system leaders use clinical decision support systems (computerized data aggregation, assessment, interpretation, and so on), and collective analytics (data integration, multisystems applications/correlation, and iterative/comprehensive implementation approaches) to inform appropriate action. All of this is an emerging area of organizational analysis called big-data analytics. Each of these data tools have their own associated activities that help define their utility and guide people through a series of steps in their translation and application as tools of prediction. (For more on big data, read last month's CE, written by the journal's HIMSS representative.)


Predictive models often use relational elements that measure the specific performance of a particular set of activities against the performance of other known activities having specific similar attributes or features. This helps leaders assess the likelihood that similar activities or situations will exhibit a particular kind of common performance-in other words, a predicted performance. This category of analysis helps in a range of disciplines, including marketing, strategic planning, data pattern analysis, customer performance, patient care consistency and similarity, and fraud detection (such as comparing the clinical or financial practices/behaviors in a single organization against the aggregate of those comparable clinical and financial practices/behaviors in similar organizations).


Calculations associated with predictive models help leaders evaluate risk or opportunity of a likely future set of actions or transactions by adjusting any current variables that could potentially affect the future. For example, clinical leaders might change one or two elements of a clinical protocol or algorithm and compare the results or impact of that change with previous or unchanged comparable clinical practices. This helps leaders make decisions that reflect real-world considerations and concerns, and recognize the necessary adjustments driven by changes in the circumstances or environments influencing particular actions or occurrences.


In descriptive models, relationships or data are quantified in a way that categorizes particular data in groups. Unlike predictive models that focus on single sets of behaviors, descriptive models look at many different relationships between variables. In this case, data are categorized by small factors or degrees of comparability to determine the intensity of the relationship between elements of the data and the utility of that intensity in predicting what changes may occur if the data are integrated. An example of this is the identification of small differences impacting quality and cost between delivering a particular package of services in an ED setting compared with delivering that same service package in an outpatient setting.


In decision models, the relationship between all the elements of a decision are compared and contrasted. The known data related to those decisions, including data that may have come from other predictive models, are used to forecast the results of any predictive decision. This is done to predict the results of decisions that involve a number of variables to determine their likely outcome and other similar outcomes against each other to facilitate the best choice. Often, scenario construction or development uses decision model approaches to compare the decisions that might be related to particular events, circumstances, or scenarios as they're affected from a convergence of particular variables and data. For example, the expenditure of particular resources covered by specified private insurance plans compared with those same services and how they're provided when covered differently by public plans or not covered at all.


The comparison between these various approaches may drive the creation of more cost-effective approaches (or insurance/payment coverage) that achieve comparable or improved patient outcomes. Depending on specific external environmental forces and how closely they characterize the assumed convergence of all internal and external forces in the scenario comparisons (prediction model) helps determine what best decision will be made. This dynamic helps inform how strategic, tactical, or operational actions may be changed to produce a more viable cost/service-effective outcome.


Adaptive leadership capacity

In the leader, adaptive capacity is indicated by his or her ability to translate innovation and change into a language that the organization can understand and incorporate that change inside of the culture and life of the organization.4 (See Table 1.) Here, the leader demonstrates an ability to bridge the products of predictive work into the effort of the organization to adjust and adapt its practices in a way that best positions itself to positively respond to emerging environmental demands. (See Figure 2.) The organization demonstrates its capacity to adapt through its ability to incorporate an innovation or change into its structures and processes in a way that's seamless and adds measurable value to the organization.

Table 1: Current pre... - Click to enlarge in new windowTable 1: Current predictions and associated adaptions

Although all change is "noisy" and potentially disruptive, rather than seen as an exception, the vagaries and challenges of this change are perceived as a normative part of the functional activity of ensuring an organization's future. In an adaptive organization, leaders are constantly aware that no process or dynamic is permanently locked into existing ritual and routine. Indeed, in highly adaptive organizations, such ritual is seen as a threat to the organization's potential to thrive.

Figure 2:. Organizat... - Click to enlarge in new windowFigure 2:. Organization adaptation

Adaptive characteristics

Adaptive organizations demonstrate particular characteristics that display their capacity to be flexible, fluid, portable, and mobile in the face of any emerging change:


1. The adaptive organization looks externally for inevitable changes in environmental forces, specifically seeking to identify how any relevant or related change will alter the purpose and dynamics of the organization.


2. At some level, every role in the organization is affected by external environmental changes. The adaptive organization seeks to be clear about what the specific impact is on individual roles with the goal of addressing this impact and making the necessary accommodation in every function of the role.


3. Reflection and deliberation regarding the environmental shift and its impact is seen by leadership as a fundamental operational obligation at every level of the organization. Time is set aside for discussion of environmental circumstances including strategic, tactical, and operational considerations. It's expected that every stakeholder be engaged in this dialogue because it can facilitate an appropriate personal and collective response.


4. Change doesn't only affect individual roles; it impacts all roles. Therefore, the ability of all stakeholders to network and interact with each other helps provide collective perspectives and enumerate particular interactions and interdependencies that influence both individual and mutual response to any change.


5. The organizational capacity to adapt and individual adaptive responses can't be driven from the top down in highly adaptive systems. The ability to flex, adjust, and innovate is directly dependent on the capacity for quick, appropriate, and timely response emerging at the point-of-service in any system. Such organizations have few levels of decision authority, lean decision/action processes, effective staff engagement models, and quick response cycle mechanisms.5



Decisions at the point-of-service

Adaptive organizations recognize that the power of effectiveness is located as close to the point-of-service as possible to ensure both timely and effective action. This type of empowerment isn't directed to simply ensure buy-in or engagement. Instead, structuring for local, point-of-service decision and action is simply recognition of what's necessary to facilitate just-in-time, effective responses to continuous short-cycle environmental and operational changes impacting all work. Adaptive organizations design structures around the work and create an independent and responsive decision cycle that will adequately and effectively respond to any and all forces impacting the work. To do this, adaptive organizations reflect the use of knowledge management concepts at the point-of-service in a way that ensures that essential information, tools, and skills are available in the right stakeholders enabling them to make the most right decisions.6


Successful adaptive organizations use the following to facilitate knowledge and adaptation:


1. Recognizing specific external forces directly impacting the context and content of work at any particular point-of-service.


2. Combining and drawing conclusions from the organization's tacit knowledge of operating in its environment and the explicit knowledge of individuals undertaking the functional work of the organization.


3. Using mechanisms of cross-reference in a way that shares insights, perspectives, and understanding from a wide variety of roles impacted by or responding to a necessary change.


4. Developing a specific capacity for emergent group process or just-in-time collective dynamics that pull together appropriate stakeholders and partnerships in an immediate-response framework allowing for timely responses to adjusting to critical change.


5. Creating recognition that a certain amount of redundancy in process is essential to countering risk and ensuring particular levels of safety.


6. Increasing focus on customization and individualization forces systems to specifically design service and care to reflect the unique needs and characteristics of specific populations, episodes, genetics, conditions, and circumstances.


7. Designing information management processes that are timely and accessible for point-of-service clinical decision makers. Adaptive organizations provide the evidence necessary to influence accurate and appropriate clinical decisions/actions that result in care effectiveness, judicious resource use, and service satisfaction. The pace of contemporary technologic change now requires all organizations to engage in continuous and dynamic innovation if they're to remain current and relevant. This infers the capacity to make dynamic changes based on shifting data and evidence in shorter periods of time. Clinicians need to interact with the most current and accurate data and information with regard to clinical practices, resource use, and effective outcomes.



A flexible, fluid future

To become more predictive and adaptive, organizational leadership must make at least three important choices:


1. Create adaptive leadership competencies. A development/training program that teaches all leaders the fundamentals of just-in-time decision making and processes, and provides the basics and tools for predictive practices, is essential to make sure all leaders are "singing off the same song sheet."


2. Shift the operating milieu of the organization. It's important for executive leaders to create structures and processes where these predictive and adaptive expectations are the drivers of strategy planning, tactical action, and effectiveness evaluation. Implanting these expectations, tools, and processes into the way of doing business every day, every place in the system creates expectations for aligned behaviors.


3. Make it safe for people to experiment, risk, and stretch as they address the vagaries of immediacy, short-term adjustments, and rapid-cycle change. Moving more decisions and actions to stakeholders at the point-of-service strengthens decision and action, and ensures more accurate and adequate response to immediate effective change.



Predictive and adaptive capacity is no longer an optional skill set within organizations and in the role of leaders at every level of the organization. Key to thriving in any health system is its ability to adjust, accommodate, and transform practices as environmental conditions, circumstances, and technology create an increasing challenge to relevance. Recent national legislative and regulatory changes, as well as the larger environmental shifts in sociopolitical, economic, and technologic forces, have substantively moved the focus of health system enterprises from volume-based activities into a value-based milieu.


Value-driven realities best articulated in the triple aim of service excellence, high-quality care delivery, and good care price management have now radically shifted the focus of health systems and the work of all clinical service providers. It's in this environment where predictive/adaptive leadership skills are highly prized, essential components of growing importance to the future of effective healthcare delivery. As health service moves from highly structured and institutional models of service delivery toward more flexible, fluid, portable, and mobile structures for service, the ongoing use of predictive and adaptive strategies will become cornerstone skills for all clinical leaders.


Historic innovations predictive of human transformations


* The introduction of antibiotics led by penicillin transformed the treatment of infections and cured many long-term infection-related illnesses.


* The introduction of commercial air travel created a global community for trade, human mobility, portability, and multiculturalism.


* Medicare transformed healthcare for older adults, dramatically extending both the quality and longevity of citizens in a short time period.


* Introduction of the microchip mobilized and made portable communication, computation, data generation and management, and the technologically-driven world.




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