In addition to courage and a strong moral compass, healthcare leaders need to be innovative. As I have outlined during the first five weeks, innovative changes are required in healthcare in order to improve the quality and safety of patient care. The lives of our patients depend on it. As I've discussed in our earlier classes, our leaders must convince everyone in healthcare delivery to adopt industrial and manufacturing, athletic principles, work in interdependent teams that are always improving. Learn from our mistakes, in order to prevent them from happening to others. Adopt tools that force caregivers to do the right thing, and that compensate for human error. We know what to do, but why are these changes not happening? The answer has been known for centuries. Here is Machiavelli's explanation in 1515. There is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies all who profit by the old older, and only lukewarm defenders and all those who would profit from the new order. Most of us do not understand the difference between technical and adaptive change. In order to bring about meaningful improvement, we all need to understand these differences. Technical change applies to traditional and accepted methods or processes. Examples. A new CT scanner, a new type of hospital bed that prevents bedsores, a new pager system. There is no change in the way things are done. There is no loss and simply a technical improvement. This form of change is easier to implement. And these types of changes lend themselves to the assistance of outside expert consultants. When it comes to adaptive change, a true change in the way things are done, initially there may be no clear answers because there is often no past precedent, there is likely to be ambiguity. Adaptive changes, often complex and consist of iterative processes that requires continual PDSA cycles. Leaders who take on adaptive change must be innovative and posses critical thinking skills as noted by Machiavelli. Adaptive change is hard to implement. Most of you were told too old to have experience the beginning of the major adaptive change shown in the right hand image. In World War II, the United States' industrial capacity had to be dramatically increased to support our war effort. For the first time, women flooded into the work force. And after almost 70 years, we are still trying to adjust. We require leaders that can effectively bring about adaptive change. We need adaptive leaders. This form of leadership has been and continues to be promoted by Harvard Kennedy School of Government senior lecturer Ron Heifetz, shown below. And in our course materials you will find a number of references to his ground breaking work. Adaptive leadership can be defined as, a leader who is able to bring about meaningful and continual change in the face of uncertainty. Where are the adaptive leaders in health care, you my ask? The lack of progress in improving the quality and safety of care suggests there are not enough adaptive leaders. Why are the so rare? Because the challenge the status quo and are perceived as troublemakers. They inadvertently make enemies because they challenge the order of things. In healthcare, in particular, most leaders make it to the top because they get along and don't make enemies. Under the right conditions, these are valuable traits, but if your organization requires change, you require a different type of leader. Because we in healthcare do not value our or understand adaptive leadership, adaptive leaders are not rewarded or advanced. And as a consequence there is very little change. What are the characteristics of a successful adaptive leader? They are innovative and encourage everyone to develop new ways to continually improve every process. Analytical, allowing them to generate logical plans for improvement and accurately access the consequences of the change. They are motivational, encouraging others to adopt and spread the change. They are open, they are transparent. They have no hidden agendas. The are willing to continuously learn. They are sensitive to the concerns of others, and are good listeners. They have courage to pursue the changes that will improve patient care, and they don't give up in the face of resistance. What are some of the examples of adaptive changes in healthcare? The biggest is Universal Health Insurance. We all have watched the continued resistance to the Affordable Care Act, despite the fact that studies now reveal that health insurance saves 120 lives per 100,000 people. Not to mention reduces the suffering caused by untreated illness. Why are so many resisting? Because it is a change. And those who profit most from the status quo continue to resist. Patients seen actively participating in medical management decisions is another adaptive change. This is an important goal, the resistance of this change continues because this approach promises to prevent push medicine, that form of medical care that leads to over-treatment and the increased profits we talked about in week two. Another adaptive change, responding to patients who are inadvertently harmed with open communication, apology, and financial compensation. As we mentioned Rick Boothman is an adaptive leader who has spear-headed this change at the University of Michigan. But despite his remarkable success either hospitals resist modifying their more defensive approach. Converting working groups into working teams. Physicians who like to be at the top of the hierarchy resist the more level structure created by effective teams. They resist despite the fact this approach can reduce errors, improve efficiency, and improve satisfaction on the part of patients and care givers. Eliminating unnecessary hand-offs and simplifying flow patterns. Too often each person within the value stream feels her contribution is necessary and important. Each worker may resist having her role reduced, and resistance often continues despite the promises of reduced patient waiting times, improved efficiency, and reduced errors. Most of us do not want to accept the fact that any part of our job is unnecessary. Unfortunately for those of us working in the fields of patient safety and patient care quality the majority of changes required to improve healthcare are adaptive in nature. Adaptive leaders are necessary. Thank you.