Decreasing Dissonant and Increasing Resonant Leadership Behaviors to Transform Health Care

Overreliance on Extrinsic Motivators

Over the past several decades, health systems have met financial targets through aggressive cost management and tightening of productivity expectations—enforced through rewards or consequences—on all aspects of behavior, from coding mix to documentation completion to quality metrics. The effect has been greater regimentation of clinicians' work, reduced time with patients, and less time for self-care and personal life, all of which increase burnout. ³

Extrinsic motivators have a place, but when they become the dominant mechanism to maintain or improve performance, leaders create 2 problems. First, they generate diminishing returns. For example, when health systems are missing budget expectations, leadership often responds by trying to increase patient appointment slots to compensate for missed revenues. That increased expectation then becomes the new baseline. When the next crisis hits and leadership tries to take another bite from that apple, clinicians will simply have less to give, regardless of whether leadership offers performance bonuses or consequences for failure to comply.

Second, the burdensome expectations crowd out any space for frontline clinicians to innovate ways to improve performance, eliminating any alternative pathways for increasing revenue without overburdening clinicians. Leaders may see transitory gains in the next quarter, but the problem will quickly resurface when clinician fatigue sets in, and they can no longer keep pace.

Threats of Punishment for Failure, Before First Seeking to Ensure Success

Many leaders conflate the broad concept of accountability with the narrower concept of holding others to account. Furthermore, they think that holding others to account means being tough on those they lead and using negative extrinsic motivators (punishment) as the main lever to keep employees aligned with expectations. Policies that dispense punishments, like withholding pay for a failure to meet specific targets, are simple and easy to track, making them very attractive in large systems. Leaders might even achieve results in the short term but at a huge cost, having demoralizing and demotivating effects.

When leaders broadly threaten negative consequences if goals are not met, they send the message that they have no responsibility for failures. Even staff who are meeting expectations get the message, fall out of line, and you might be next. Rather than inspiring the best in everyone, such tactics isolate individuals and drive them into a defensive crouch, minimizing their ability to be creative and engage in transformational work.

In contrast, resonant leaders understand the value of shared accountability, taking personal responsibility for ensuring that everyone understands who is accountable for which goals and that everyone has the tools and support to accomplish the goals for which they are accountable. When staff feel leaders support them and want them to succeed, they feel energized and see failures as opportunities for growth. For example, to successfully meet quality metrics in value-based contracts, leaders might be tempted to focus primarily on bonus incentives to influence provider behavior.

Yet, providers will drown under the weight of increased expectations unless leaders also ensure that (1) provider teams are configured and staffed to manage new expectations, (2) providers are given adequate space and primary responsibility for optimizing team performance, and (3) leaders overtly share ownership for missed targets and promote constructive dialogue to guide teams to hit targets the next time.

Consolidated and Reduced Transparency of Decision Making

Leaders have responded to challenging finances over the past several years through repeated cost cutting and layoffs. ⁴ Though initially tolerant of the tough decisions made by leaders, employees often passively resist or actively challenge them. In response, leaders get defensive and consolidate decision making among a small group. That in-group is typically transparent to everyone, but the mechanism for decision making is opaque. Decisions are announced but even relatively high-ranking managers are caught off guard or entirely cut off from the process.

When leaders make decisions without operational input from frontline staff, they are often wrong, usually not implemented, or if implemented, have little impact. ⁵ Yet, the negative outcome is not limited to the immediate failure to improve operational performance. Everyone becomes fearful, mistrust balloons, and contempt and despair surface. This toxic fallout creates a feedback doom loop through which leaders feel justified in excluding employees who have responded exactly as predicted, and double down. Rather than doing things with people, they start doing things to people. To everyone else, the decisions seem arbitrary. Even if they are reasonable decisions, no one will perceive them as such.

In an environment of mistrust, employees who stay learn to withdraw and stay silent, usually doing the bare minimum to get by or focusing on their own safety and advancement rather than the mission of the organization. Meanwhile, those who leave do not feel safe saying why they are leaving for fear of retribution. Instead, they bide their time until the first reasonable external opportunity comes along, then walk out the door with a smile on their face. The tragedy is that resonant leaders, who have a reservoir of trust that they foster and replenish tenaciously, can deliver tough messages, and retain buy-in and positivity because they communicate their belief in people as partners rather than assets. That belief keeps employees around even during tough times.

Disconnect Between Language Used and Actions Taken

The previous section outlined the problems with consolidated decision making and a lack of transparency that torpedoes trust. Leaders often make the situation even worse through discordant communication patterns. The authors identified 3 problematic communication patterns. First, leaders undercommunicate or fail to communicate entirely when communication is crucial. In these situations, fear pervades because no one knows what is going on. Undercommunication is often a sign that leaders are unsure of what they are doing or are worried about how people might respond. In either scenario, mistrust and fear will fester.

Second, leaders effectively deploy the language of transformation, using inclusive language, promoting innovation, and painting a serviceable vision of the future through emails or meetings. However, they fail to follow through with clear plans and actions that mirror that language. Alternatively, they might bring in consultants that give the appearance of action and may even implement the first steps of a new process, only to revert to the status quo or, at most, reshuffle minor or irrelevant parts of the process in ways that produce no meaningful change. Over time, employees stop believing and approach meetings and reading emails through the lens of cynicism.

Third, leaders send contradictory messages, particularly messages that are at once both inclusive and exclusionary, empowering and disempowering. This commonly happens when leaders feel strongly about a course of action that is likely to negatively impact 1 or more key constituencies. Anticipating resistance, they try to include impacted stakeholders in the hopes of diminishing resistance to change. But unless leaders intend to truly incorporate feedback and alter the course of action, what initially feels like collaboration will end up feeling disingenuous and create bad feelings on both sides.

When leaders become convinced of their infallibility and elevate the quality of their decision making over those who know more, rebuilding trust is all but impossible. In contrast, even when decisions are tough, resonant leaders are transparent, respectful, and humble. Such resonance is crucial to keep the team together and motivate action, whether times are tough or not.

Reinforcement of Siloes and Hierarchy to Control Processes

Many leaders practice a command-and-control style. They feel pushing decision making to the frontline as much as possible is risky and unpredictable. Even well-intentioned leaders who truly want to nurture innovation struggle not to micromanage processes, instead becoming incredibly focused on the “how.” To accomplish this, they lean heavily on hierarchy: categorizing tasks in siloes and resting responsibilities with direct reports, which propagates the illusion that everything can be controlled. Unfortunately, rigid siloes crush innovation and impede change, leaving mid-level managers focused on their position within the organization rather than on the transformation at hand. Eventually, those managers end up either competing with each other and rooting for their peers to fail or wondering why they are present at all.

Resonant leaders achieve great results because they believe deeply in the capabilities of those they lead and work doggedly to unleash their potential. They know that it is the potential of those employees that drives transformational change. To tap into that potential, resonant leaders create a vision so that employees understand why and where they are going and inspire staff to figure out how to get there. Once leaders set that expectation, they broadly outline what objectives are necessary to achieve that vision.

Resonant leaders do not tell teams (who know the work far better than leaders) how to accomplish the goal. Instead, they shift away from hierarchical-driven change that focuses on who is in charge and toward change focused on achieving goals. Siloes are broken down to promote staff interaction across a range of functions and capabilities, allowing good ideas to be elevated, and imperfect ideas to meet, mate, and evolve into groundbreaking innovation.

Conclusion

The authors believe deeply in the value of effective leadership, but such leadership is in short supply in health systems around the country. Furthermore, they suspect that the epidemic of burnout in health care ⁶ can be traced, in large part, to misguided dissonant leadership. Although not all causes of burnout are easy for leaders to control, deploying a resonant leadership style and minimizing dissonant leadership behaviors can have a huge impact on the mental wellness of your workforce.

Effective transformational behaviors are not easy to practice when organizations are under great financial stress. The leader must be both humble and hopeful, warm and fierce, and mindful and communicative. Yet nearly everyone can improve the performance of their organizations if they recognize when they are practicing dissonant leadership behaviors and change to resonant leadership behaviors. The first step is recognizing when you are getting it wrong.