By Bob Sachs, PhD, Board Member of TLD Group & We Care Services for Children, formerly Vice President of National Learning and Development, Kaiser Permanente
As the board chair of a not-for-profit agency, We Care Services for Children, that provides mental health and developmental services for young children and their families in the San Francisco Bay Area, I am acutely aware that since the pandemic began, there has been an increase in the number of children and young adults with behavioral and mental health issues.
This concern for the well-being of children was also raised by Dr. Kevin Churchwell, the president and CEO of Boston’s Children’s Hospital. In a January 2020 interview with McKinsey, Dr. Churchwell discussed the response needed to tackle the critical mental health needs of children. Prior to the COVID-19 pandemic, he thought that the number of children being seen per day with these issues was already too high. As the Boston area moved further into the pandemic those numbers increased substantially. He then raises an important question, “How do we create a system of care for children with behavioral and mental health issues that currently doesn’t exist?”
Dr. Churchwell believes that if we are not going to “lose this generation” we need a continuum of care that encompasses the family, the primary-care pediatrician, the school system, the hospital, and the state to provide the necessary response. He recognizes whether that solution develops “is based upon how we coordinate and collaborate to create that continuum.”
The Growing Need for Reform Requires A Health Ecosystem Approach
Dr. Churchwell’s view of how to address the growing concerns about children’s mental and behavioral health is consistent with what Tracy Duberman, PhD, President and CEO of TLD Group, and I wrote about in From Competition to Collaboration, How Leaders Cultivate Partnerships and Drive Value to Transform Health. Our book discusses the need to move from a narrow focus on delivering sick care to a focus on enhancing and maintaining health by taking an ecosystem approach. What we call the health ecosystem encompasses Dr. Churchwell’s care continuum.
We see the health ecosystem as the interconnected relationships between leaders, organizations, and sectors — such as providers, purchasers and payers, pharmaceuticals, biotech organizations, public/private sectors, communities, and entrepreneurs that can and should work together to improve health, including mental health, in the community.
When we authored our book, the concept of the health ecosystem was just emerging. It is now seen by many as foundational to improving access, affordability, and health. Over the last few years, the number of collaborations across sectors of the health ecosystem has expanded with participants increasing the breadth of their participation and many new participants jumping in to collaborate and/or compete with traditional players. Fortunately, some of these collaborations have demonstrated real success.
The response of many key players to the COVID-19 pandemic has illustrated what is possible — such as the adoption of telehealth, vaccine development, and deployment and care coordination — when leaders from different organizations and diverse industry sectors rally to meet a critical health challenge and align around a common purpose. This success was driven by the urgency of the COVID-19 emergency. And while numerous reports describe the accomplishment of the involved organizations, organizations do not make key decisions, identify key partners, or invest resources. These actions need to be developed and executed by leaders who operate with an ecosystem mindset and demonstrate health ecosystem leadership skills.
Our book outlined this leadership mindset and skill set under the rubric of HELM (The Health Ecosystem Leadership Model). The response to the crisis in child mental health that Dr. Churchwell discusses, and that I see as board chair of the agency here in the Bay Area, requires leaders who continue to demonstrate these capabilities. That is, they must:
Envision the Future: Develop a clear vision, direction, and perspective on what is required for success that recognizes the views and potential roles of multiple stakeholders in the health ecosystem.
Align Stakeholders: Engage with the potential stakeholders, incorporating their interests, ideas, and capabilities, and use these interactions to develop the trust and respect needed to overcome the inevitable barriers that will arise as collaborative efforts move forward.
Manage Tensions and Obstacles: Initiate difficult conversations and despite inevitable conflicts remain focused on the opportunity of the collaboration by minimizing self-interest, recognizing complementary areas of expertise, and working together to develop solutions that further the identified purpose.
Act and Learn: Act under uncertainty that is inherent when exploring innovative ideas, while actively seeking feedback along the way and adapting plans as needed.
Apply for our 12-week Health Leadership Ecosystem Institute course to master the HELM™ capabilities to positively impact results within their own organization and across sectors and industries that span the health ecosystem.
Knowing What to Do Is Not the Same as Doing it
In our work with leaders, we have found that while these capabilities are intuitively valid, knowing what to do is different from doing. We see people widely recognized as strong leaders failing to consistently demonstrate the HELM mindset and skill set.
We also see leaders like Dr. David Carmouche, who is SVP, Omnichannel Care Offerings at Walmart Health, a former senior executive at Ochsner Hearth and Blue Cross, who strive to consistently and effectively demonstrate health ecosystem leadership. As David recently told us, he has found this awareness and focus on health ecosystem leadership is important because demonstrating these capabilities is more difficult than most people realize. He has observed that it is far more natural for leaders to focus on narrow interests, quick results, and efficiency than it is to create a shared future, align stakeholders, confront conflict, act under uncertainty and learn from what works and what does not.
None of this is surprising, or is it limited to people operating in leadership roles. The central thesis of the book, Think Again, by Wharton professor, Adam Grant, is that all human beings are terrible at rethinking what they believe and are highly resistant to changing their minds on matters great and small. Even when trying to think differently we are subject to multiple unconscious cognitive biases that can limit our view or point us in the wrong direction. Fortunately, these biases can be managed and must be if we are to successfully achieve real transformation and change as referenced by Dr. Churchwell, “a system of care for children… that does not currently exist.”
Creating a New System of Care for Children
The fundamental role of any organization’s not-for-profit board is to ensure that the organization effectively develops and utilizes its resources to serve the community consistent with its mission. The We Care board continually evaluates the agency’s programs and services to assure they are impactful. We participate in planning to explore ways to better meet needs, oversee the development and use of financial resources, and assure the legal and ethical integrity of the organization. Key to these activities is a capable, diverse board that works closely with a strong leadership team, starting with our executive director. As board chair, there are multiple ways I try to support each of these efforts. The HELM capability framework has been helpful with many of these responsibilities, particularly in my interactions with the executive director.
To bring this to life, below I share how I have used the HELM mindset and skills to help the agency move toward the new system of care that is needed to assure as many children as possible can realize their full potential. While I will discuss the HELM capabilities in sequence, it is important to recognize that although each capability builds on those that precede it, the actual demonstration of HELM is not linear. Leaders often move back and forth between capabilities as a collaborative process unfolds and issues appear that require a return to a previous set of capabilities.
Envision the Future
When building a picture of the future, leaders need to develop a broad perspective of the landscape in which their organization operates. This requires maintaining an open mind to possible causes of the problem(s) being confronted, the patience to take the time to understand multiple factors that could contribute to the issue, and identifying diverse stakeholders who can help understand the opportunity or contribute to the solution.
Actively seeking people who are from different specialties, expertise, and experience and taking the time to understand their thoughts on the problems being faced is critical. Looking for parallel concerns faced by other organizations and by members of the community, taking the time to understand how they see the problem, the solutions they are pursuing, and what they are trying to accomplish can be very enlightening. It is not unusual to find many more groups trying to solve the same or related problems than is initially realized. Identifying and seeking the input of these stakeholders has the potential to create a significant impact, particularly with complex problems.
Our agency must consider the views of many diverse groups, starting with our existing stakeholders. We know that the services and funding provided by the county are key, so an understanding of the county’s perspective must contribute to the vision for the solution. We need to understand how they see the situation, what capabilities they can contribute, what positive outcome they want, and what priorities motivate their current approaches.
Because we have worked with the county for so long, it’s easy to assume that we know the views of its key representatives and base our approach on those assumptions. During conversations with the executive director, I ask questions to help him to reexamine his existing assumptions and encourage him to maintain an open mind while he continues to engage with county leaders to explore the future they want to create. We also have conversations about seeking to understand the views of other not-for-profits that offer similar or complementary services to the groups we serve. As a not-for-profit, we always need to consider the views and interests of current funders, like foundations, corporations, and individuals, as well as any potential funders who might have an interest in our vision.
Because our goal is to create a new system of care we need to go beyond these existing groups. We ask ourselves who else cares about helping children and their families with developmental, behavioral, and mental health issues? We begin to think about what might be better accomplished if worked together than on our own. As one example, we see a need to consider religious organizations, many of which support communities that have not always felt comfortable receiving services from community agencies like ours, as we envision potential solutions. The views of the hospitals in the area like Dr. Churchwell’s Boston Children's Hospital, and of the community physicians that serve the same population are also important perspectives for us to understand and incorporate in a possible future.
Aligning Stakeholders is fundamental to success. Successful collaborations require leaders who can actively engage stakeholders representing diverse sectors and whose capabilities can contribute to the desired outcomes. Leaders must build high degrees of trust and shared purpose to effectively integrate differing views, quell tensions, and work through disagreements. We know the more comprehensive and diverse the organizational operations, perspectives, culture, and expertise of the potential stakeholders, the harder it is to achieve alignment. Yet, these differences also offer the greatest opportunity for innovation and broad impact.
Lack of attention to aligning stakeholders is a primary contributor to derailing collaborative solutions. Participants in a recent HELM leadership course identified their ability to create stakeholder alignment as the most difficult to master. One of the participants who was having difficulty advancing her selected challenge said it this way, “Perhaps the most important lesson I learned moving through my challenge was the need to build in time to test my assumptions, step back from my original plan, and encourage open dialogue and exchange of interests, ideas and perspectives with all parties.”
Leaders need to reach out to the stakeholders identified in their vision, share that vision, and then invite input while being clear that the vision will evolve as new ideas are surfaced. Members in newly forming groups need to have the time to get to know each other and to understand each other’s perspectives and interests. The successful leaders will put their assumptions about the other organizations and sectors in the room aside and actively ask questions to better understand the purpose, priorities, and operations of each represented group and the background and skills of each of the participants. These discussions need to be conducted in a manner that builds trust, develops a shared direction, begins to identify potential solutions, and starts to surface how each organization and individual might contribute to those solutions.
We Care has begun this alignment process while continuing to broaden its vision and to identify participants that need to be involved in the work. Our executive director is leading a group made up of diverse stakeholders in the area. While these organizations are more similar than different in purpose and services, each agency serves a different part of the county with varying needs and has different strengths and funding levels. The group has started to go beyond meeting the individual needs of each agency to focus on some common concerns and surfacing opportunities like shared training and administrative services. Together they have successfully advocated with some of the county departments to adjust funding in response to service needs and staffing challenges. These early successes have added to the trust levels that were already present. They have now begun to engage with leaders and elected officials in county government to look at longer term needs. The future we have envisioned has identified many other stakeholders to engage. The challenge to building alignment will grow as the diversity of the group increases and there will be a lot more work to do in building and extending trust and aligning interests.
None of the above is easy. It is not unusual for our executive director, who knows how important it is to achieve these important results, to want to move things along by offering solutions too quickly. He and I talk about the need to pursue inquiry before advocacy; to sometimes go slow to go fast. There are also times when it seems easier to do what we can on our own. When this comes up, we spend time re-visiting the vision we are pursuing and discuss the conditions that need to be in place to achieve that future.
Manage Tensions and Obstacles
Moving from conceptual alignment to plans and actions typically presents many hard issues:
- How are decisions made and who makes what decisions?
- How are resources identified and deployed?
- Whose resources are utilized?
- How are information and data shared?
Issues like these are inevitable. How successfully they are resolved determines if the plans move forward. Step one is to surface the conflicts. Once again, this is easier said than done. We avoid conflict because it can be uncomfortable or worse, disrupt work and relationships. We need to move from a natural tendency to avoid conflict to seeing it as an opportunity to create better solutions and further build relationships.
When we do encounter conflict, our typical response is to defend. This response narrows solutions and will often curtail emerging collaborations. Managing defensiveness begins with remembering the worthwhile purpose that brought the group, with its diverse views and capabilities, together and then taking the time to understand what is important to each party involved in the conflict, and why those things are important. As with aligning stakeholders, it’s important to postpone developing solutions until this understanding is in place. Once there is a clear view of the important interests of each stakeholder, the group can move to solutions that best accomplish the shared purpose of the collaboration while minimizing the negative impact on any stakeholder.
Adam Grant presents an approach to conflict in Think Again that has proved to be helpful as our executive director and I discuss conflicts that he is facing as he works to move closer to our vision. Grant says that people approach conflict in one of four modes. We preach, trying to convert others to our beliefs; we prosecute, trying to win our case or defeat the “opponent” or we politic seeking others to support our solutions. Each of these modes places our own views at the forefront, reducing our opportunity to understand other ideas and ultimately placing others on the defensive.
Grant suggests that productive conflict occurs when we operate in the fourth mode as a scientist, treating our emerging views as hypotheses, testing our ideas with data, and updating our views as we receive new information and learn from others. Our executive director and I find this framework helps to successfully utilize the scientist's mindset. My frequent reminders to ask good questions and to listen more than he speaks pop up frequently enough in our conversations that he can finish what I am in the process of saying.
Act and Learn
New ideas, by their nature, have not been tested. In a world where people are evaluated on results, and not achieving results is often treated as a failure, trying something new or untested involves risk. Successful leaders get beyond this uncertainty by creating plans as a series of actions. This approach helps mitigate risks by allowing for frequent evaluation and course correction. Ideally, all the critical stakeholders are involved in the planning, in defining metrics to measure progress, reviewing feedback, and adapting plans. When all are involved in this process the chance of quitting the effort when outcomes are slow to be realized is reduced because people are prepared for that possible result and are ready to evaluate and adapt. Rather, stakeholders stay focused on the overall purpose that was developed as the group came together and they see setbacks as opportunities to learn and progress.
At We Care, we have had several examples of abandoning prototypes when early efforts failed. Using HELM, in retrospect, we have learned that in most of these cases the vision was not fully developed or shared, the role of some of the stakeholders was not well understood or agreed to by all the key parties, and conflicts tended to be avoided. Basically, we had not effectively demonstrated the other three HELM components. When this foundation is shaky the likelihood of successful action is effectively zero. We are using this learning to approach new efforts more effectively.
We have also had several successes including our response to the need created by the COVID-19 pandemic. We Care has been around and successful for a long time. The agency strongly believed that our traditional service model of in-person developmental programs and face-to-face therapy, often delivered in a child’s home environment, was the best way to work to support children. These approaches had to be abandoned when COVID-19 hit at the same time the needs of the children and families we helped grew. We, like a lot of organizations, pivoted to offer learning opportunities and therapy sessions online.
Importantly, when we approached the county, which funds many of these services, it allowed reimbursement for these remote services. We have seen many children benefit from these remote sessions and, while we have returned to in-person delivery, we also continue with online modes. Online services have a real benefit. They can improve the productivity of our staff, who need time to drive from home to home, and make it easier for families, who must find ways to get their children to our sites, to receive services. This mixed approach allows us to reach more children efficiently and effectively than we had before.
Clearly, the pandemic pushed us out of our comfort zone. We saw a very stark picture of our future when COVID surged. This threat aligned key stakeholders, including our teachers, therapists, the county, and the families we served, around our shared purpose of helping young children. The pandemic helped to minimize some of the concerns and resistance we would have encountered if we had tried to introduce these approaches during more typical times. It moved us to action. The learning and success we had in implementing these changes will help us move forward during “normal” times to create the new system of care that Dr. Churchwell and we know is needed to assure that all children can realize their potential.
The decisions leaders make and the actions they take make a huge difference. The mental health and development needs of children highlighted by the pandemic must be faced. We need leaders who consistently and effectively demonstrate the capabilities described in the health ecosystem leadership model (HELM) to take on this challenge and the other significant gaps in our health system that impact affordability, access, quality, and health equity. These capabilities can be built and enhanced with intention and focus. Whether that happens is up to all of us who are leaders sharing a common interest in improving the health of our communities.
Apply for our Health Ecosystem Leadership Institute’s 12-week blended course to build the leadership capabilities needed to drive this transformation and the collaborations and partnerships it requires. As an open enrollment program, the Institute brings leaders together from diverse sectors to learn from and with one another and fills the void left by traditional single organization/single sector leadership development programs. For more information about the course and to apply, visit our Health Ecosystem Leadership Institute.