(Chapter of “Learning Organizations – Developing Cultures for Tomorrow’s Workplace”, Edited by Sarita Chawla and John Renech, Productivity Press, 1995)
My objective in this chapter is to illustrate the challenge of building learning organizations in a service industry which has to reinvent itself amidst drastic and multifaceted changes. This challenge calls for stewardship among healthcare leaders – the ability to see a broader picture and to take a long-term view. As Peter Block defines it, stewardship is also the willingness to be accountable for the well-being of the larger community, by operating in service of those around us.
The First Trillion Dollar Industry
The healthcare industry needs to learn to become more effective : already the largest industry in the country with over one trillion dollars in health outlays estimated for 1994 (i.e. 15% of the Gross Domestic Product), it will double in size by year 2000 if the current growthrate of 13.5% per year is maintained. The cost per capita of the U.S. healthcare system is already twice the average of twenty four industrialized countries and represents a growing economic handicap when competing on global markets. And yet, at least 15% of the American population do not have regular access to the system. These issues of cost and access have put healthcare reform in the limelight since the 1993 presidential election, and it is likely to remain one of the most controversial political issues over the next few years. However, enhancing health is a much broader societal issue than reform of access and payment mechanisms. We need to build healthier communities and this will require a widespread sense of stewardship.
Over the last five years, I have personally become involved in healthcare as an educator and a facilitator by teaching leadership development seminars for healthcare executives and by facilitating meetings and retreats for approximately thirty organizations. The focus of my work has been to help managers, physicians and board members explore and apply – personally and collectively – the disciplines of learning organizations. Although healthcare reform has now undeniably become a powerful motivator for change, a number of these organizations took a creative approach to learning by committing to Continuous Quality Improvement (CQI) several years ago. Over the last two years some of them have chosen to collaboratively explore ways to accelerate their learning in a program called “Transforming Healthcare Delivery”.
I still have a lot more to learn about healthcare and its organizations. I write this in a spirit of exploration and dialogue with other “change agents” concerned by this industry and the lessons it may offer for other components of society. I will first review the forces at work in healthcare and point to the key shifts in thinking and behavior needed to build a system that would work for all of its stakeholders – the vision. Next, I will share my perception of the specific obstacles to learning in healthcare organizations – the current reality. I will then illustrate the path followed by some organizations to move from current reality to vision, both individually and collaboratively, and emphasize the leadership challenge that these changes represent. I will conclude with some generic learnings for organizations in other fields.
Forces At Work And Basic Shifts Needed In Healthcare
I heard recently a physician executive tell his audience that healthcare is no longer going through white waters : it is already over the falls ! This may be particularly true for hospitals and physician specialists in some exposed markets like large cities in California, Minnesota, Oregon and Washington. But most other healthcare organizations may think they have a few years to prepare themselves for radical changes, depending on the speed and depth of both reform implementation and organizational consolidations.
What needs to emerge in the long run is a new healthcare system which truly enhances the health of all concerned – patients and providers alike. Health may be defined as the ability to function as close as possible to one’s physical, emotional, mental and spiritual potential. A number of basic shifts in thinking and behaving, all systemically interconnected, will be at the core of this transformation:
- – The first major shift now under way concerns the payment base for healthcare providers: from fee-for-service (or full-cost reimbursement) to contracted care (services paid for at a discounted rate) and to capitation (annual or monthly fee per enrollee, irrespective of the services provided). It means that hospitals and physicians will become accountable for the health of a given population for a fixed sum of money. Most of them have already some experience of contracted care (e.g. with Medicare, Medicaid and large employers), but only Health Maintenance Organizations (HMOs) such as Kaiser Permanente or Group Health Cooperative of Puget Sound have an in-depth understanding and practice of capitation. The gradual move to capitation – from less than 20% currently on the average to probably over 80% of total payments in a few years – will make most providers responsible for the quality and the cost of healthcare, instead of continuing to behave like the vendors to the Department of Defense who contract on a “cost-plus basis”. It will become impossible for them to shift the cost burden to other categories of patients, contrary to what they have done until now.
- – The shift to capitation will accelerate another trend already under way: from mostly in-patient – acute care involving an overnight stay in the hospital – to more and more out-patient procedures which are much less costly. New technological advances in testing and surgery amplify this trend. Experts predict that more than half of the existing 900,000 in-patient beds will need to be closed or converted to out-patient facilities by year 2000. A number of the outpatient services may not be located on the hospital campus but in decentralized clinics, closer to where patients live or work. Ambulatory care (including mobile units), home care and other alternative services are also being developed and demand some radical rethinking about hospital boundaries, investments and relationships for hospital administrators and physicians alike.
- – A related shift is already affecting the relative importance and status of specialists vs. primary-care physicians. Traditionally, specialists have been more influential and highly paid, thus attracting the vast majority of medical students to specialized medicine. Primary care physicians are now increasingly considered as the key to success in capitated care, and their role as gate keepers and care managers of the new healthcare system will be increasingly rewarded. In the more exposed markets, the oversupply of specialists and the high demand for primary care physicians are already forcing specialists to become generalists, move to another town or retire early. Ultimately, both primary care and specialized physicians who have behaved mostly as individualistic entrepreneurs will have to practice medicine in a collegial way to offer the best quality care at an acceptable cost.
- – An even broader shift will bring healthcare providers from a production orientation to a customer-focused service orientation. Hospitals and physician specialists have thrived largely by maximizing the utilization of their facilities : beds, operating rooms and elaborate testing premises. Most resources have gone to high-cost in-patient acute care in hospitals that look like modern factories and often compete with one another to attract the best referring physicians in the community with the latest piece of equipment. This “medical arms race” has left very little for prevention, education and health maintenance; and most administrators and specialists still expect the patients to come to the hospital rather than connect with them preventively wherever they live, study or work.
- – In the longer term, it is clear that only a shift from the “illness” to the “wellness” paradigm will enable this country to afford its healthcare system. Education and prevention cost less than one tenth of the price of a cure, as recently illustrated publicly with immunization programs for children. But the only access which is now offered to uninsured or indigent people is through the emergency room, a very costly access from all viewpoints. A new goal must be to help everyone feel responsible for their health and offer them guidance and incentives to use healthcare providers as resources and partners. This a far cry from considering the doctor’s office or the hospital as a repair shop to take one’s body when it suffers the consequences of one’s lifestyle. Acute care will, of course, continue to be necessary for emergencies and unavoidable illness, but resource allocation will be more balanced between cure and prevention when we have given up the addictive behaviors of today’s healthcare system. Healthcare organizations should take the lead in building healthier communities and collaborate with health officials, local government agencies, employers, schools and churches. Healthcare providers need to increasingly behave as custodians of people’s health in their community. In the long run, they are likely to find that it is more satisfying and rewarding.
- – The shift to the wellness paradigm will be accompanied by a greater recognition of the effectiveness of alternative medicines and the self-healing capacity of the individual. A 1993 article in the New England Journal of Medicine reported that Americans made more visits to providers of unconventional therapy (chiropractors, acupuncturists, homeopaths, massage therapists, etc.) than to traditional primary care physicians in 1990 although they had to pay for most of them out of their own pocket. A PBS television series with Bill Moyers entitled “Healing and the Mind” showed powerful and moving examples of how we can call on our inner resources, as well as on support groups, to deal with terminal illness and promote healing. A better balance between traditional Western medicine and now-called “alternative treatments” will need to be achieved in a more effective system.
- – Another set of shifts concern the healthcare organization as a working environment. It needs to become a healthy place for providers of care, giving up frequent addictive behaviors such as blaming, workaholism, excessive stress and burnout. It should also move from a hierarchical and fragmented structure to a service-oriented, patient-focused, team-based and networked organization. It needs to become a community of learners, living out shared values – including service and compassion – and valuing the contribution of everyone, rather than be run like a “business machine” emphasizing only efficiency and short-term financial performance. The organization as a whole should become focused on long-term results and stop rewarding quick fixes.
Key Learning Disabilities
Healthcare organizations differ greatly from one another, but most of them seem to have some learning disabilities in common due to the nature and the history of the industry.
- – Most hospitals are highly fragmented organizations, where an extreme degree of specialization is compounded by different personal reactions toward suffering and terminal illness. Most of the specialists – administrators, physicians, nurses, technicians, etc. – have been trained in their own disciplines and strongly identify with their profession, and there are very few “natural bridges” among them. For instance, physicians have not usually been trained in interpersonal skills or organizational dynamics, and administrators do not generally know much about medicine or the medical problem solving model. Each specialist/ person may also react differently to suffering or death and thus can feel even more isolated from the others (e.g. a physician doing research on terminally-ill children vs. the nurse in charge protecting them from painful procedures out of compassion).
- – The increase in size and complexity of most hospitals has widened the split between physicians – M.D.s in charge of clinical care – and administrators – MBAs in charge of the rest of the organization. This split often materializes as minimal understanding of each other’s issues and a lack of common language (except when investing in clinical equipments that doctors want). Diametrically opposed incentives tend to reinforce this split particularly as the proportion of fee-for service payments begins to decrease; for example, multiple tests prescribed by a physician to reduce the risk of malpractice suits increase the cost of care. A vision shared by a hospital and its physicians cannot be successfully implemented unless most of these incentives are realigned.
- – Other traditional polarizations aggravate the lack of alignment and sound communication within a healthcare system: primary care practitioners vs. specialists, physicians vs. nurses, clinicians vs. support services, acute vs. non-acute care, personnel and activities located on the hospital campus vs. disseminated “out there” in the community. Just as between administrators and physicians, these polarizations result from a lot of untested assumptions, attributions and generalizations about each other.
- – The clinical and administrative habits inherited from a long history of fee-for-service may also stand in the way of the new behaviors that are now required of the key stakeholders. The “medical arms race” between hospitals in the same community – which led to bed and equipment overcapacity in many cities – as well as ambiguous relationships between hospital and physicians have generated a lot of distrust among parties that now need to contract and collaborate together for their own survival and a better service to the community. Board members who have been mostly driven by somewhat narrow financial considerations and have not consistently expressed the voice of the community must also renew their role and their relationships with administrators, physicians and other civic leaders.
- – Many healthcare organizations have a well-entrenched history of reactive behaviors -“quick fixes” that become addictive when confronted with changes such as new regulation, inflationary costs and increasing competition from HMOs. They have practiced cost shifting, across-the-board cost cuts and discounting without understanding the longer-term consequences of their actions. When confronted by new challenges such as capitation and clinical outcome measurements, they may be tempted to look at re-engineering, continuous improvement teams and visioning as another wave of quick fixes, without realizing the underlying changes in the management philosophy that these approaches imply. Most healthcare organizations have been late adopters of CQI and several factors tend to limit the effectiveness of their efforts: a predominant emphasis on tools and techniques, a lack of early involvement of clinical staff and customers in selected projects , as well as an insufficient number of managers retrained as facilitators and resources.
- – As in other industries, the high turnover/instability of senior management is a barrier to learning, particularly with the increasing need to build stronger relationships with the medical staff and within the community. It is aggravated in a number of cases by the board’s or parent organization’s focus on short-term results and a mounting wave of mergers, acquisitions and nation-wide consolidations.
- – The lack of physicians willing and/or prepared to take on leadership roles within their group practice, a new Physician-Hospital Organization (PHO) or the medical staff can hamper the growth of healthcare organizations that need to be increasingly co-led by administrators and physicians. Doctors have some strong points to build on as leaders but most of them also need to experience some basic shifts in their ways of thinking and behaving due to their selection process, their primary training and the conditioning of years of practice. But too few courses or seminars focus now on the personal changes which are critical to the development of leadership skills that many physicians will need to demonstrate in the new healthcare context.
- – Another obstacle to be overcome by most hospitals is the lack of deep relationships with the community as a larger health system. Community outreach is often limited to fund-raising and very few have engaged in active collaboration with employers, health-related services or other providers. A number of trustees are still mainly focused on the financial performance of the hospital and may lack the broader view that would enable it to become a proactive force for the community health. When the organization’s purpose and values-in-use do not reflect a concern for the larger system of which it is a part, it may experience a conflict between a public service mission and a business logic that is likely to be reinforced by managed competition in reform proposals.
- – Finally, one of the main obstacles to generative learning may be the level of fear that is now increasing among physicians, managers and employees of hospitals around the country. Several related factors tend to feed this fear: increased competition from large HMOs and hospital chains; large-scale consolidation and integration leading to change of ownership and hospital restructuring or closing; change in the respective capacity of health plans, hospitals, specialists and primary care physicians to capture and distribute the available healthcare dollars; reduction in specialists’ income due to overcapacity and cost containment efforts; and uncertainties about the depth and speed of healthcare reform. Economic survival may become the main motivator for many providers, and thus prevent them from learning through creative experimentation and making mistakes.
The Transformational Path
Moving to a more effective healthcare system will initially require some political intervention to change the rules of the game because the system has been unable to reform itself from within. In an article entitled “No More Band-Aids for Healthcare Reform”, Kellie Wardman has used the systems thinking archetype called “tragedy of the commons” to characterize the existing state of the system: as the early settlers abused the common pasture by blindly pursuing their self-interest and grazing more and more cattle, so have all healthcare stakeholders – patients and their families, physicians, hospitals, insurers, employers, federal and state governments – individually contributed over the years to the current cost and access breakdown of the healthcare system. Everyone has conspired through short-sighted or addictive behaviors to build a system that is not sustainable in its current form.
However, fundamental change will fully materialize only if individual healthcare organizations take the lead in overcoming obstacles to learning and help create healthier communities. A small number of them have already proactively started their journey on the path of self renewal and transformation, without waiting for the threat and specific measures of political reform. They recognize that they need time to accomplish the basic shifts that will be required of them and their constituencies; some of them are stimulated by the rate of change already affecting their community. Here is a brief account of some of the most significant efforts already underway in the organizations I have worked with or known about over the last five years:
- – A majority have started building a shared vision by involving their senior executives, leading physicians and board members in imagining what they would want to create together to best serve the needs of their community and the other stakeholders, three to five years from now. Community leaders were sometimes invited to reinforce the voice of the primary customer – the community.
One or two “visionary planning” retreats usually provided the initial impetus for the vision-based process. Participants first reflected on their personal values and vision for their work life, before they shared their views of what the organization would mean for its key stakeholders and what measures of success would be appropriate in the future. In the same spirit of dialogue, they would then share their perceptions of current reality and identify the key areas of creative tension between vision and reality. The session would be concluded by a consensus on the key strategic priorities enabling them to bridge the gap, on the ground rules that would help them to dialogue, learn and work most effectively together, and on the next steps needed to extend the vision sharing process throughout and outside the organization.
The main retreat was often preceded by shorter educational workshops that gave board members and physicians an opportunity to internalize some of the new external challenges and to reflect on the shifts needed in their respective thinking and behavior patterns. In most cases, the retreat was integrated into the overall strategic planning process in order to take advantage of the environmental and internal assessments that are normally included in that process. But the main difference with a traditional strategic plan was in the high level of individual and collective commitment to achieve measurable milestones that would lead to the realization of the vision.
- – In a few cases, the visionary planning process was enhanced by “Idealized Design” sessions involving one or several stakeholders – administrators, physicians and board members, but also patients, payers or community leaders. In these sessions, participants were asked to imagine that the existing system had been destroyed. They were invited to envision a new one that would best meet the combined needs of all stakeholders in the current or most probable environment. The absence of current constraints and the playfulness participants brought to this exercise generated very creative insights and bold proposals that were later integrated into the vision and the redesign of the organization. One example was a “healthcare mall” integrating outpatient services, primary care physicians, nurse practitioners, social services and a wellness center.
- – In several organizations, managers and physicians have been introduced to the concepts and language of systems thinking in conjunction with vision sharing. These sessions enabled them to acknowledge their part in creating current reality and to empower themselves to modify structures at their level in order to move toward the vision. The application of systems thinking in mixed teams on critical issues has also allowed them to surface and challenge mental models that stood in the way of breakthrough thinking and solutions; for example, some of them realized that health plan enrollees and primary care physicians would need to be the primary focus of the new system, not the hospital; others were able to see the long-term vs. short-term trade-off involved in investing more consciously in health education and prevention.
- – At least two of these multiple hospital systems also explored the practical links between Idealized Design, systems thinking and process re-engineering. They realized that many of their continuous improvement team efforts could lead to costly duplication of efforts between units without addressing some of the key leverage points for the system as a whole. They decided to reframe their priorities through a customer-idealized design that led to the re-engineering of patient care across the multi-hospital system and to the streamlining of the corresponding CQI projects. Another organization – an HMO – used Idealized Design to rethink and streamline its strategic planning process, from the internal users’ perspective.
- – In a few communities, an on-going dialogue has been initiated by one of the local healthcare providers to enable local leaders to surface, inquire into and remove underlying barriers to a more affordable, high-quality and coherent healthcare system for the area. Participants include representatives from competing providers, dominant payers and employers, health and local government officials and other major providers. After six to nine months, they have gained critical insights about the nature of the current system’s incoherence and have built a safe enough climate to start dealing with major issues and tensions that had been historically undiscussable. The next steps should allow them to design some new solutions and guide pilot projects within the community.
- – Finally, most of these organizations have begun to invest consistently in the development of their leadership teams – board members, leading physicians, senior and middle managers – realizing that learning must start at that level. The visionary planning retreats mentioned earlier were usually a first step in that direction, because they included work on personal mastery, as well as team building and team learning activities.
To go further and accelerate their learning, eight hospital systems decided two years ago to join a healthcare learning collaborative which has proven to be very worthwhile for all participants, as described below.
In all of this, the dedication of senior leadership to personal and organizational learning and their “consistency of purpose” have been critical for the transformation of the organization; this will be the subject of the last part of this chapter.
The Learning Collaborative entitled “Transforming Healthcare Delivery” was created in 1992 by the Healthcare Forum to offer participants similar benefits to those enjoyed by the members of the MIT Organizational Learning Center (see page __) : access to specialists of the learning disciplines, pooling of resources to pursue action research, opportunities for exchange of experience, benchmarking and stimulation. In addition, the industry-specific nature of the Collaborative would enable it to address generic healthcare issues and to jointly develop new learning tools at a crucial point in the evolution of the healthcare system.
As it approached the end of its grant from 3M, the Collaborative truly became a learning community for the 24 participants from the eight systems. This group met for three days every three to four months in a different city, hosted by one of them. The members, called “bridge builders”, were introduced to practical applications of the five learning disciplines and particularly to the complementarity of visioning/ Idealized Design, systems thinking and total quality approaches. They experienced having a dialogue around complex issues, where everyone takes the time to inquire into the quality of their thinking; this activity was even more worthwhile as they represented a wide variety of organizations in size, management philosophy and market conditions. Participants shared some of the applications and experiments they conducted at their sites with the help of the Collaborative’s faculty.
They also contributed to the development of two learning laboratories and tested an organizational learning assessment tool. The learning labs called “Mastering the Transition to Capitation” and “Strategic Management in an HMO” now enable the bridge builders – trained as facilitators – to expose a number of managers and physicians in their organization to practical applications of systems thinking and to challenge prevailing mental models, thus increasing their alignment around a shared vision.
Highly satisfied with these results, Collaborative members have decided to continue learning together in a modified format, but with the help of the existing core facilitators. Some of the participants have volunteered to help facilitate learning labs and other sessions in organizations other than their own, recognizing the value of cross-organizational experiences and of learning by teaching. Two or three organizations with similar interests might be added to the original group to increase the diversity and richness of the Collaborative. And the next steps will probably lead to the development of additional learning laboratories in areas of mutual interest of the members.
These first two years have also underlined a few conditions for the success of collaborative learning across organizational boundaries: it is helpful to have organizations with a similar maturity level on the learning continuum (e.g. with some experience of CQI and vision building); senior executives and line managers need to commit to a multi-year program and to involve themselves personally in the learning sessions; non-competition between members helps create a safe environment for sharing all relevant experiences; a core team of facilitators combining general and specialized skills should be involved in and between the meetings to help structure a cumulative learning experience and increasingly involve the participants in designing and co-leading the sessions; there must be a willingness to experiment in content and format from session to session, and a commitment to dialogue and collaboration (i.e. to public reflection on the experiments and learnings); participants should also be encouraged to take the time for exchanges through computer networks and site visits between the general sessions; finally, a focus on personal development and on challenging one’s mental models should be adopted from the beginning and sustained throughout the multi-year program.
The Less-traveled High Road
My experience with individual organizations and Learning Collaborative members confirms that not just learning but also stewardship needs to be demonstrated by leaders in order for these two operating principles to permeate the entire structure. Senior executives, leading physicians and board members should set the tone by challenging their own mental models, self-concepts, roles and behaviors, and by developing new leadership skills. These times of drastic change for healthcare require courage to stay the course in the quest for self-mastery and deep learning, especially with all the pressures for short-term performance that come with highly visible positions.
Administrators, directors and physicians alike need to experience some of the following shifts in their role and self-concept : from a driver of change to a “gardener of people” who sees the potential in others and helps create the conditions for them to grow and reveal themselves; from appearing learned – someone who is supposed to and therefore pretends to know – to being a learner who doesn’t hesitate to admit “I don’t know”; from behaving as a problem solver or a “turn-around expert” to acting as an architect or designer who discerns the emerging patterns and gradually transforms the various structures that condition human behavior; from being perceived as an authority figure and a charismatic visionary to becoming a midwife of others’ visions and a custodian of the shared vision, particularly when times get tougher; from being ego- or image-driven to becoming a servant-leader.
Taking the high road of stewardship first means to commit to the path of self-mastery which includes: being in touch with one’s deeper values and aspirations; understanding one’s own deeper dynamics and self-limiting patterns; being open, vulnerable and compassionate; accepting ambiguity and some discomfort as part of the learning process; “walking the talk”; being capable of detached involvement (i.e. being passionately committed to the path without getting too attached to the outcomes); managing one’s energies to achieve results with an economy of means; and living a balanced life which includes time for exercise, family life, community involvement and self-development.
It also means developing new skills such as recognizing different patterns of human dynamics and the deeper capacities that exists in everyone; engaging in and facilitating dialogue by being mindful and present; seeking and building on diversity; taking time to build relationships; thinking systemically and helping others gain a broader perspective; continually testing theories and challenging mental models.
My work with individual organizations and with the Learning Collaborative has enabled all of us to experiment with some new methods of helping leaders who want to accelerate their own development and that of their associates:
- Dr. Sandra Seagal’s Human Dynamics approach offers a deep and practical awareness of the different patterns of learning, communicating and working with others, as well as of the deeper capacity that exists potentially in each of us and can be developed. Coupled with work on personal vision and values, this approach enables leaders to venture safely onto the path of self-knowledge and to engage in dialogue and team learning on a much sounder basis.
- Dr. Joan Kenley’s work on developing human capacity opens new avenues for leaders who want to explore and use more of their internal energetic resources to be more present to their experiences and achieve results with greater clarity, ease and inner strength. As the CEO of a leading- edge healthcare system puts it : “With the help of this work, I feel more integrated and more at ease with myself as I meet my daily challenges”.
- Dialogue groups and learning networks, through meetings and computer conferencing such as the Healthier Communities Fellows of The Healthcare Forum, also offer great opportunities to develop and practice the mindfulness which is so critical for true inquiry and communication. They are quite complementary to the new learning labs or management practice fields that help uncover and challenge mental models associated with the key shifts needed in healthcare and service activities in general.
- Finally, some leadership development seminars – including a new program designed for physician leaders – focus on the practical exploration of the new stewardship qualities and combine the approaches described above. An expanded version of these programs will be offered in a new center located in the Sierra Nevada – the Montreux MetaResort, scheduled to open in 1996 – which will combine physical, emotional, mental and spiritual regeneration for individual leaders, their teams and their families.
In conclusion, some key lessons emerge from dealing with change in an industry that is undergoing fundamental shifts:
- Organizations that can commit to investing in their own gradual transformation – while facing radical challenges and undergoing budget restrictions – are more likely to succeed in the long-term than those addicted to quick fixes and heroic turn-around efforts.
- Leaders at all levels must be willing to anticipate and address important but less urgent issues in spite of short-term pressures; they need to allocate time and resources to a transformation process which doesn’t yield immediate results; they demonstrate their courage and determination by “staying the course” over several years; they proactively address the stewardship challenge by investing significantly in both personal and organizational development.
They understand that self-transformation enables organizational transformation and community development which, in turn, foster further personal development in a upward spiral. They are also willing to experiment with new approaches and tools which help challenge prevailing mental models and habitual behaviors, without falling into the trap of the management “fad of the year” which generally breeds cynicism throughout the organization.
- Learning collaboratively with other institutions can accelerate an organization’s progress toward meaningful change, particularly when a number of industry-specific issues can be best addressed in common, and when a safe environment is created which encourages public reflection and thorough sharing of experience among participants. It enables organization representatives to reach a much deeper level of understanding and insight than what is commonly referred to as benchmarking.
- Finally, stewards recognize the need to transcend the boundaries of their organization and to include other stakeholders in creating a learning community . They gain a sense of what needs to emerge for the greater good, realizing that not all visions are created equal.
When leaders become stewards, acting in service of their organization and their community, they inspire others to do the same and can tap both the personal dedication and the collective intelligence that are needed to deal with changes as complex as those faced by healthcare organizations, schools, businesses and governments in our society today.
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