Sexual Assault at UVA: 4 Lessons in Crisis Leadership

There are better ways to handle a situation like the one that has ignited a firestorm at the University of Virginia.

The turmoil that has enveloped the University of Virginia since Rolling Stone magazine’s publication of a scathing article describing a gang-rape at a fraternity party and a university culture “less concerned with protecting students than it is with protecting its own reputation from scandal” has done more than tarnish the reputation of a prestigious public institution. It has produced a primer on how not to lead during a crisis.

The Nov. 19 article included graphic references to a UVA coed, called “Jackie” by the author, who told the magazine she had been raped by seven men at a fraternity party. The article described a university culture in which sexual assaults “are kept quiet” not only by the university administration but also by students “as regrettable but inevitable casualties of their cherished party culture.” Later that day, UVA President Teresa Sullivan issued a statement saying, in part, that the university “takes seriously the issue of sexual misconduct” and that Charlottesville police were being asked to investigate the alleged rape. Then she left the country for a previously scheduled conference.

That’s when all hell broke loose. Students, faculty, alumni and others were outraged not only that a coed had allegedly been gang-raped but also that university officials had apparently done nothing more than offer their support to her. Dozens of current and former UVA coeds wrote to Rolling Stone describing their own rapes on the campus. A Charlottesville newspaper reported that Sullivan and others at UVA had learned of the alleged gang-rape in September but had done little except talk to fraternity leaders.

Sullivan became the focus of much of the outrage from the UVA community. How, some asked, could she refer to gang-rape and other criminal activities as “sexual misconduct”? Why didn’t she cancel her trip and address the firestorm of protests? In response, Sullivan announced that UVA was suspending all fraternities and associated parties until early this month. She also talked in much stronger terms about the problems of sexual assault on campus and promised a long-term effort to change the culture at UVA. Virginia’s attorney general announced that he had asked a prestigious law firm to investigate the rape allegations. And Rolling Stone’s editor acknowledged major discrepancies in the article and apologized, raising the question of whether the gang-rape had actually taken place — and leading to yet another storm of anger and protest.

Any institution facing such a situation needs strong, proactive leadership. To be fair, Teresa Sullivan is a caring, honest human being who has worked hard to improve the welfare of students, faculty and the institution. In this instance, however, her leadership has been flawed. Sullivan’s and other UVA leaders’ inability to understand and deal effectively with the crisis they face is a cautionary tale for all leaders and an important reminder of four key crisis-leadership principles:

• Be wary of the initial information that emerges during crises. In our rapid-fire desire for quick explanations, it’s easy to accept the first reports about a major event. The problem is that those reports are often wrong. After the 1999 murders of 13 people at Columbine High School, some students and school officials said that the two shooters had been victims of school bullying and were acting out of revenge. That explanation was quickly accepted by many professionals who work with kids. But 10 years later, David Cullen wrote in his carefully researched book Columbine that the two were not victims of bullying; indeed, he reported, one of them was often the perpetrator of bullying. Much of the information in the Rolling Stone article about UVA is now suspect, but UVA leaders initially accepted it as fact, creating serious problems for many individuals and groups.

Crisis leaders must resist the temptation to accept the first reports they receive and aggressively seek as much information as possible before taking decisive action.

• Listen carefully to people with sound judgment. President Sullivan’s immediate actions after being told in September of the alleged sexual attack seem woefully inadequate. So, too, were her first comments when the Rolling Stone article appeared two months later. Then, just days later after the article created a firestorm of anger, she switched gears and made very strong statements about rape. People were left wondering why she leapt from a passive response to an aggressive one. Her faltering responses raised an important question: What kind of advice — if any — was she getting as the crisis unfolded?

It’s very difficult to get a sense of perspective in the middle of a crisis. That’s why it’s so important to call on people whose judgment you trust, people who owe you nothing and have experience with the issue you’re facing.

• In crises, communications are (almost) everything. There may be excellent reasons why UVA officials refused for over a month to respond to multiple requests for records related to the alleged gang rape and wouldn’t say whether the report to be issued by the law firm would be made public. Those reasons were not divulged. Thus, some people wondered whether UVA leaders had something to cover up.

The crisis leader’s most precious asset is trust. During a crisis, the leader’s most critical task is to communicate sincerely, openly and consistently with all stakeholders.

• First protect people; think about reputation later. This is one of the most difficult principles for many crisis leaders, especially those who work in agencies with very strong cultures, such as law enforcement, fire/emergency services and transportation. When such agencies experience a crisis that exposes them to strong criticism, they sometimes circle the wagons and point the finger elsewhere. Such defensiveness is understandable, but it is usually counterproductive, as UVA’s leaders have learned.

Crisis leaders need to put their focus squarely on the needs of the people they serve, irrespective of the criticism being leveled at their organization. When people see leaders showing a passion for protection, when leaders focus all of their energies on handling the crisis professionally and openly, reputation usually takes care of itself.

When the Best Intentions Lead to Disaster

The VA scandal has its roots in two related management failures. Government leaders everywhere should keep them in mind.

As the Department of Veterans Affairs begins the long, difficult and expensive process of addressing the problems that led to its scandal over falsified wait times for veterans seeking medical appointments, government managers who want to keep their own enterprises out of the same kind trouble would do well to look at the elements that brought the VA down.

At the heart of the VA scandal is the falsification of records in the face of a huge surge in veterans needing care and insufficient resources to serve them. One study by federal auditors found that, while official VA reports claimed that some vets waited 24 days for an appointment, the average wait time was actually 115 days. And there is another, equally troubling aspect to the scandal: the harsh reprisals to which VA workers who tried to report wrongdoing were subjected.

At the core, I think the VA’s problems were driven by two factors: the misuse of performance measures and an agency culture that didn’t respect candor.

On the performance measures problem, VA leaders made an understandable and common mistake. To get employees’ attention, they put a huge emphasis on a single measure: All vets will have an appointment at a health clinic within 14 days of their request. Given the mismatch of demand and resources, there was no way the staff could achieve that laudable goal. Nor did the goal make sense: Vets with serious problems should be seen immediately, while it’s reasonable for those seeking an annual checkup to wait several weeks or more. Further, many supervisors’ bonuses depended on the performance numbers. Put these factors together — one all-important but unreachable goal, with one’s pay riding on the outcome — and it was a disaster waiting to happen.

To some, the candor issue might have been surprising. After all, former Veterans Affairs secretary Eric Shinseki spent three weeks in the field each year holding dozens of meetings with employees and supervisors at which he insisted on candor. But the bad news never got to him. It’s not hard to see why. A VA scheduler had to decide whether to listen to the supervisor sitting down the hall who said to game the system or to the department’s top leader who meant well but was thousands of miles removed. Tragically, all too many followed their supervisors’ orders, and those who didn’t were often punished.

So how do you turn this situation around? Provide mandatory ethics training? Fire the supervisors who told staff to cook the books? Bring in a whole new team of leaders and managers?

Management consultants often say that “what gets measured gets managed.” But when you have a single, impossible-to-achieve, high stakes measure, nobody should be surprised when some people game the system. A far smarter approach is to use a version of “the balanced scorecard,” which captures data on four key performance areas: financials, customer satisfaction, internal operations and employee learning/growth. Many public and private organizations have used versions of the scorecard with good results. There is no one meaningful metric that captures all that matters in an agency. Adopting a few (emphasize few) measures is far more realistic and effective.

In addition to using a balanced set of measures, managers need to involve employees and supervisors in devising those measures. The measures need to be ambitious but not impossible; they need to focus on things that staff has the power to control. They need to give managers and supervisors (as well as external stakeholders) data that they find useful. The VA’s all-important metric — a health-care appointment within 14 days — failed each of these tests.

As for the second issue, the VA story demonstrates that candor is vital to achieving the mission. Shinseki, a public servant of great integrity, was sincerely interested in getting honest feedback from front-line staff, but staff didn’t feel it was safe to speak up. What can agency leaders and managers do to create an open, candid environment? Here’s a starter list:

• Model candor at the top. When leaders acknowledge mistakes that they or their agency have made, it sets the right tone.

• Talk about the reasons that candor is so critical. The point isn’t candor for its own sake (although that’s a good thing). It’s to continually spot problems and opportunities for improvement.

• Craft a simple narrative that highlights the cost of stifling candor. NASA’s Challenger tragedy wouldn’t have happened had NASA’s managers been open to the engineers who tried to warn them that it was too cold to launch the spacecraft. If you say, “We can’t have another Challenger disaster” at the space agency today, people quickly understand the message.

• Work closely with your middle managers; they are the key. When senior managers frequently meet with those in the middle, they should ask them what’s going well and what isn’t, and make it safe and rewarding to talk openly about problems. When middle managers experience the power of operating in an open environment, they let their guards down and realize that candor improves agency performance (as well as their own careers).

The Department of Veterans Affairs is in serious trouble. So are other public agencies that relentlessly track one high-stakes measure and that allow retaliation to replace candor. We should all take a lesson from the VA.

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You Can’t Manage a Secret

Creating a culture of openness and candor is critical to organizational success. It takes a strong, concerted effort by leaders.

“Problems don’t get better with age.” So says Colin Powell, the former military leader and secretary of state, and he’s absolutely right. But how do you get people to bring problems to senior managers’ attention when the culture has rewarded just the opposite? The recent stories of General Motors and Ford illustrate powerfully how a culture of openness, or the lack of it, can make or break any organization, private or public.

Many were outraged when it was revealed earlier this year that GM had decided back in 2005 not to spend about a dollar per car to change an ignition switch that eventually was linked to the deaths of 13 people. What’s equally outrageous, in my view, is how little GM’s CEO, Mary Barra, knew about this problem. Barra, to be fair, is new to her job and had no role in the ignition-switch problem. But when she was presented with a number of facts about the long history of ignition-switch failures while testifying before Congress, she seemed unaware of them. And when asked why it took GM 10 years to even acknowledge the defect, she had no answer.

How could it be that the chief executive officer of a major corporation knew little about a decade-long problem that ultimately led GM to recall 2.6 million cars, resulted in at least 55 lawsuits against the company and will cost several billion dollars in fines and settlements? How could this icon of U.S. industry allow the ignition-switch problem to fester for a decade without recalling the faulty vehicles and without notifying federal authorities (as required) and the public?

The answer seems to lie in the company’s culture. For decades, GM was plagued with warring fiefdoms, so it wasn’t in one’s interest to surface problems in front of your colleagues. And even when problems were brought to senior managers’ attention, action was often impeded by poor communications between GM units. As crisis-management expert Gerry Meyers puts it, “In any big organization, there’s an effort by lower-level management to insulate upper- level management. And the more layers there are, the less [likely] that a very serious matter can get to the top.”

GM’s problems were hardly unique. From the 1980 until the Great Recession, the Big Three became arrogant, bloated in the middle and top, unwilling to learn from competitors, and increasingly disconnected from what car buyers wanted.

But there’s a very positive side to this story, and it comes from Ford. In 2006, Alan Mulally was hired away from Boeing to be Ford’s CEO. Ford veterans were amazed; some were mystified. After all, Mulally wasn’t a “car guy” — he’d spent his entire career working in the aircraft industry. True, Mulally wasn’t an expert in car design and mechanics, but he knew how to create an open, candid corporate culture, which was exactly what Ford needed.

One of Mulally’s early moves was to initiate a weekly Business Plan Review, where Ford’s senior executives meet to review the previous week’s performance numbers. From the start, Mulally required openness. His mantra was, “I can’t manage a secret!” He repeated it continually. Everyone at these meetings was expected to discuss current and anticipated problems along with their plans to address them.

After a few of these meetings, someone brought up a significant challenge. Mulally said, “So-and-so has a problem. He’s not the problem. Who can help him with that?” Soon, everyone got the message: Your responsibility is to the team and the company; you’re expected to be open. Nobody is criticized for having a problem; you’re only in trouble if you don’t raise the problem early or if you have no ideas for solving it.

These meetings, and the message they sent around the company, have been a major reason for Ford’s success under Mulally. The company, which lost over $14 billion in Mulally’s first year, has been solidly in the black for years, with strong customer satisfaction scores to boot. And Mulally has received multiple awards for his leadership, including being named 2011 CEO of the Year by Chief Executive magazine.

Colin Powell once said, “The day the soldiers stop bringing you their problems is the day you stopped leading them.” Alan Mulally says, “I can’t manage a secret.” Different words, same sentiment. Effective leaders foster a climate that invites and rewards openness and candor. What are you doing to create such a climate?

Innovation and Government’s Fear of Failure

When it comes to trying something new in the public sector, we’re especially averse to risk. But there are ways to gain support for these kinds of initiatives.

“Why can’t government be run like a business?” How often have we heard that question? In my mind, many government functions should be run in a business-like fashion; help-desk units, customer-service offices, financial transactions and dozens of other government activities should seek out and adopt the best private-sector practices. But many Americans really don’t want government to act like a business if that means investing their tax dollars in innovative (and thus risky) programs.

Any experienced entrepreneur knows that the process of innovation involves trial and error, and often failure. Think of your favorite high-tech companies. Many of them — Apple, Twitter and PayPal, among others — began with failures. Indeed, Silicon Valley entrepreneurs have a mantra: “Fail fast, fail often.” They know that you rarely get it right the first time. Develop the product, get the “beta version” in the hands of some users, learn what doesn’t work, fix it and repeat the process until you have a winner.

While most Americans are delighted to use the amazing products that survive this process, we are ambivalent at best about the risks of innovation in the public sector. Take Solyndra, a clean-energy startup that received over $500 million in federal loan guarantees and left taxpayers holding the bag when it went bust in 2011. Politicians and many other Americans were outraged, and it became an issue in the 2012 presidential campaign. Yet when the signs of a resurgence in clean-tech companies became apparent in 2013, few in the media bothered to cover it.

So it’s easy to understand why so many elected officials and public managers are risk-averse when it comes to innovation. The risk/reward ratio just isn’t in their favor. Except … except that Americans are also extremely proud of a host of innovations that came directly from government — things like land-grant universities, the Interstate Highway System, the technology underlying the Internet, drugs to treat a host of ailments, effective law-enforcement approaches such as “broken-windows” policing and CompStat, and hundreds of products developed from NASA research, such as safety grooving on our highways, aircraft de-icing systems and cordless phones.

Each of these were innovations, none of them were guaranteed to work, and all of them cost considerable money to develop. Now there is no constituency to eliminate any of them. But today, when government officials announce an effort to do something new and unproven, powerful constituencies emerge to argue against it.

What to do? How can public-sector leaders overcome risk aversion and gain support for their innovative projects? Here are some strategies to consider:

“Sell” the problem. “The cost is high, other (traditional) approaches fell short. Avoiding the problem is irresponsible.”

Manage expectations. Don’t promise the world. Call it a pilot, start small, focus on learning.

Be realistic about risk. Describe where this approach has been tried, and the results.

Partner wisely. If working with a private firm is appropriate to the task, find a respected company that has experience with the approach.

Develop a constituency. Seek backing from well-respected individuals in the community who have no self-interest in the program and believe it’s a legitimate role for government.

Compare what you want to do with other programs: The U.S. government, for example, has been funding cancer research since the late 1960s. We haven’t found the cure, but the need is huge and the public supports ongoing research.

Play to pride: “This is America. We don’t back away from the tough ones. We’re a can-do people.”

And perhaps the most important strategy is patience. Take the long view. It may take years to get the needed support to launch an initiative, guide it through the inevitable failures and setbacks, and finally see results. That’s a cost innovators learn to pay. And it’s often well worth it.

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The Dilemmas of Leading in a VUCA World

Today’s turbulent environment of volatility, uncertainty, complexity and ambiguity means new challenges for government managers and policymakers. There are ways to cope with them.

Suppose you’re a state legislator. You’re about to vote on a bill that would impose significant regulations on hydraulic fracturing, the controversial process for extracting natural gas from shale rock whose use has skyrocketed in the past decade.

Depending on your perspective, “fracking” is providing us with a clean, inexpensive energy source or it is a major health threat that poisons the air and water around drilling sites. Proponents point to lower energy costs and lower greenhouse-gas emissions. Opponents cite more than 160 cases of drinking-water contamination near fracking sites.

Do you view fracking as a blessing that reduces our reliance on polluting fuels while it produces jobs? Or are you more focused on its health and safety risks? It’s possible that many of the questions raised by fracking will be answered in the coming years. But you have to vote today. What’s your decision? The fracking issue illustrates the dilemmas of leading in what some call a “VUCA” environment. The term VUCA — for volatility, uncertainty, complexity and ambiguity — was coined by staff at the Army War College in the late 1990s to describe the challenges posed by our increasingly turbulent world.

Let’s look at each VUCA element:

Volatility has to do with the nature, speed and magnitude of change. Fracking is a great example. In 2000, just 1 percent of U.S. natural gas came from shale; today that figure is over 25 percent and rising rapidly.

Uncertainty relates to the unpredictability of issues and events. Information about the past and present are less and less useful in anticipating the future, making it extremely difficult for decision-makers to forecast and allocate resources effectively. Scientists can’t predict the long-term impacts that fracking will have on local environments.

Complexity, the multiple and difficult-to-understand causes of problems, poses another challenge. Some scientists note the high level of carbon dioxide around fracking sites due to the heavy equipment used, while others point out that carbon emissions in the United States are at a 20-year low because of a major switch from coal use to natural gas from fracking.

Ambiguity adds to the other three factors. Ambiguity makes it difficult to understand the meaning of fast-moving, unclear and complex events. Does fracking represent an important “bridge” source of fuel as we develop renewable energy sources or is it a risky short-term fix that poisons groundwater and diverts resources from our search for long-term energy solutions?

In thinking about fracking (or immigration reform, or the growing gap between rich and poor, or a host of other complex issues), your decision is clouded by risks, uncertainties and a lack of time to sort them out. What to do?

I work with a number of managers who are trying to navigate this VUCA environment. Here are some of the approaches they’re using:

Continually scan and learn. VUCA environments require that we learn from big-picture thinkers from different disciplines and industries. And such learning can reduce the “U” in VUCA — uncertainty.

“Get up on the balcony.” This notion, from the book Leadership on the Line by Martin Linsky and Ronald A. Heifetz, reminds us to periodically separate ourselves from daily operations to get a broader perspective. Leaders can do this in a variety of ways, such as visiting other organizations, listening to customers, thinking from the perspective of their boss’s boss and practicing the art of “managing by wandering around” — listening carefully to staff.

“Be quick/don’t hurry.” This concept, from legendary UCLA basketball coach John Wooden, relates to the velocity aspect of VUCA. We have to quickly note potential threats and opportunities in the environment. Whenever possible, however, we have to push back on the demands to take immediate action. We need time to separate the “signal” (meaningful factors) from the “noise” (the data points that aren’t related to the core issue).

Fire bullets, then cannonballs. In their book Great by Choice, Jim Collins and Morten T. Hansen write about the need to test your plan in small, low-risk ways and make adjustments before moving to full implementation. This is similar to the open-source software principle of “release early, release often, fail fast.”

Be agile, and find others who are agile. If there is one common thread in the growing literature on VUCA leadership, it’s the need to be very agile and to create an environment that rewards agility and flexibility in others.

“Always keep the main thing the main thing.” Jim Barksdale, the former CEO of Netscape, made this his mantra. While it’s important to continually innovate and be agile, Barksdale emphasized the critical importance of preserving your organization’s “main thing” — its core values and critical capabilities. At the U.S. Government Accountability Office, a core value is politically neutral competence. At 3M, continual innovation is a core capability. Such organizations protect their main thing at all costs.

We used to say that “the only constant is change.” Now we say that “the only thing to expect is the unexpected.” Either way, we’re living in a VUCA world.

What Legacy of Leadership Will You Leave?

Nurturing the next generation of leaders is one of the best things you can do for your organization.

On April 13, 1888, Alfred Nobel picked up a French newspaper and saw a headline announcing that he had just died. He didn’t find the error amusing (it was his brother who had passed away). But when he continued reading and saw the text of his own obituary, it left him despondent. It began: Le marchand de la mort est mort (“The merchant of death is dead”) and went on to say, “Dr. Alfred Nobel, who became rich by finding ways to kill more people faster than ever before, died yesterday.” Alfred Nobel was the inventor of dynamite.

Over the next few years, Nobel reflected on how he wanted to be remembered, and decided to change his will. When he died in 1896 at the age of 63, the public was amazed to learn that he had designated over 90 percent of his considerable fortune to the creation of a series of prizes for those who confer the “greatest benefit on mankind” in such areas as chemistry, physics, literature, medicine and peace. The first Nobel prizes were awarded in 1901.

Fortunately, none of us is likely to read our own obituary. But it’s worth pondering the question: How do you want to be remembered? Or, more to the point of these columns, how do you want people to remember you as a leader and manager?

I’ve asked some of my students that question and their answers vary:

“I want to be remembered for my creativity.”

“I want people to recall how much I cared about the agency and its mission.”

“What’s most important to me are the programs I created and their impact on others.”

Here’s another way to consider your legacy at work: Who have you helped to become a future leader? In today’s wildly chaotic organizational environment, it’s often very difficult to see the difference we have made at the end of a day (or a month or a year). But leaders can make a huge difference in the lives of the people they work with, and helping someone develop into a strong manager and leader is both visible and highly satisfying. Leaders who see part of their role as being a coach, mentor and teacher can have a profound impact on the people around them.

When I began teaching, a colleague befriended me and allowed me to sit in on some of his classes. He was (and is) a gifted teacher. Using humor, creative exercises and the example of his own behavior, he helped people try out approaches that they never had considered before. I was eager to learn from him, and asked him to observe my classes and give me feedback.

Once, when I asked him why a particular class was going poorly, he observed me teaching for a few hours and then offered this thought: “Russ, you reminded me of a doctor who caught his patient’s disease.” He was aware that some of the students had come into class with a negative, skeptical mindset. Rather than responding by maintaining a positive attitude, he saw me descending into the negativity around me. And the way he captured that dynamic — “catching a patient’s disease” — stayed with me for years. He taught without trying to, through the power of his example and insights.

Some time ago, an editor for the New York Times wrote a column about recent Nobel Prize winners. The editor had called to congratulate them and talk about their accomplishments. He then posed one question: “What helped you get where you are today?” The most frequent response? “There was a teacher.” Not necessarily a teacher in the formal sense, but there was someone in most of their lives who became a mentor and took a special interest in them. The Nobel recipients described a person who saw special potential in them: a talent, a passion, an unusual ability that they hadn’t seen in themselves. And their mentors pushed and prodded and found ways to bring out their best.

Those mentors can look back and take enormous satisfaction in the legacy they helped create. I think Alfred Nobel would approve.

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The Rider and the Elephant: Switch Book Details How to Create Change

A remarkable book provides leaders with a practical, simple framework, based on the latest brain research, for turning an organization to a new direction.

If you’d like to read a book on making organizational change happen that’s very practical, organized around an easy-to-understand framework and filled with great examples, I recommend you put “Switch: How to Change Things When Change Is Hard” at the top of your summer reading list. The authors, Chip and Dan Heath, successfully integrate the latest brain research into a simple (not simplistic) model for leading change, and they delight the reader with amazing examples told in a smart, colorful manner.

The model has three parts, all of which are demonstrated in this extraordinary story.

On Dec. 14, 2004, Don Berwick, who was then CEO of the Institute for Healthcare Improvement (IHI), delivered a talk at a hospital administrators’ convention. Berwick had ideas for saving large numbers of lives by significantly reducing the “defect rate” of certain procedures using process-improvement procedures that had been very successful in other industries. His research convinced him that these procedures would make a huge difference, but he couldn’t require physicians to change their practices. So he challenged the hospital administrators in the room to step up.

“Here is what I think we should do. I think we should save 100,000 lives. And I think we should do that by June 14, 2006. ‘Some’ is not a number; ‘soon’ is not a time. Here’s the number: 100,000. Here’s the time; June 14, 2006, 9 a.m.”

No doubt the administrators’ jaws dropped. But Berwick was just getting started. He then spelled out six specific interventions that had been shown to save lives (such as keeping a pneumonia patient’s head elevated at a certain angle so that oral secretions wouldn’t go into the windpipe). But the administrators needed more than information; they had to be motivated to take on the many barriers to change in their institutions.

Berwick then introduced a mother he’d invited to the convention. The woman’s daughter had died because of a hospital’s medical error. Then a second person spoke, the chair of the North Carolina State Hospital Association, who said that “an awful lot of people for a long time have had their heads in the sand on this issue [of injuries and death caused by hospital errors], and it’s time to do the right thing. It’s as simple as that.”

The campaign save 100,000 lives began. IHI provided participating hospitals with step-by-step instructions on how to implement the new medical procedures, the research base for these procedures and training. IHI also helped the hospitals’ leaders communicate with each other through a weekly conference call (as many as 800 people participated), and arranged for the most-successful hospitals to mentor those that joined the campaign later. Many physicians resented the new procedures, but those procedures soon produced impressive successes, and in the months after Berwick issued his challenge more than 3,000 hospitals joined the campaign.

And on June 14, 2006, precisely at 9 a.m., Berwick announced that the participating hospitals had exceeded their goals: The campaign had prevented approximately 122,300 avoidable deaths. Moreover, hospitals were institutionalizing the new procedures, ensuring that uncounted lives would be saved in the future.

At first glance, this may seem to be an exciting story about an inspiring, risk-taking leader. But there’s far more to it than that. The authors of “Switch” use this and other examples to illustrate their framework for leading difficult changes, one built around current understanding of the human brain. As the Heaths explain, our brains have two key parts that affect our decisions and actions:

• The logical, rational side, which analyzes our options and thinks long-term. It is very good at self-control. The authors call this “the rider.”

• The emotional side (a much larger part of the brain), which feels pleasure, pain, love, empathy, and so on. It’s more short-term-oriented and demands instant gratification. The authors call this “the elephant.”

Our rider tells us we need to change our diet and use the gym regularly if we really want to shed 30 pounds; our elephant won’t let us walk past the Ben and Jerry’s without trying the latest flavor. If you visualize a rider sitting atop an elephant, you understand the dilemma: The elephant is far larger and stronger than that lonely rider.

On the other hand, the wise and rational rider doesn’t provide energy for change; indeed, the rider is often at risk of “paralysis by analysis,” getting lost in the facts and options. That’s why our elephant is so critical: We don’t make difficult changes without feeling highly motivated. So we need both rider and elephant pulling in the same direction to successfully change.

Let’s take another look at the campaign to save 100,000 lives through the lens of the “Switch” framework. Berwick appealed to the hospital administrators’ rider through his documentation of the problem. He gave the rider a clear destination (save 100,000 lives by June 14, 2006) and explicit directions (six interventions that were known to save lives). Berwick also hooked his audience’s emotions — their elephants — through the two people he introduced at the conference.

There’s a third part of the “Switch” framework, called “shaping the path” by making the change easier. In Berwick’s campaign, the path to change was simplified through the use of step-by-step instructions and support groups. The weekly conference call enabled real-time communications among hospital leaders. And the campaign helped those hospitals that weren’t making progress by connecting their leaders to colleagues who had started earlier and were experiencing success.

The Heath brothers have given us a path to leading change that will appeal to your rider as well as your elephant. It’s a delightful read, and a very important book.


The Perils of Tunnel-Vision Leadership

The leadership fight at the University of Virginia is a powerful example of why so many change efforts fail.

Pop quiz. What do the following have in common?

• The new director of a large state agency initiated a visioning process two months after taking over. She told her staff, “I’ve had very good success using this in my previous management roles and am excited to use it to help this agency move forward.” Six months later, after strong employee pushback, she asked her deputy why there was so little enthusiasm for the visioning initiative. His response: “This is the third visioning exercise we’ve had in two years; the other two didn’t go anywhere, and nobody expects this one to either.”

• A federal agency dealt with a budget shortfall by doing a cost-benefit analysis of its regional offices. Its Alaska office proved to be the least efficient, and the agency announced it would close that office. The agency’s leaders hadn’t bothered to communicate with Ted Stevens, one of Alaska’s senators at the time who happened to be chairman of the powerful Senate Appropriations Committee, or with Alaska’s House member, Don Young. Twenty-four hours after announcing the decision, the agency was forced to reverse course and maintain the Alaska office.

• After winning election, a new governor named four senior members of his campaign team to lead important state agencies. They worked hard to implement the governor’s agenda for change. Like the governor, they had little confidence that their civil servants were up to the job, and they brought in numerous consultants and new staff to lead change initiatives. After two frustrating years, all four agency leaders had left state government, convinced that they were torpedoed by careerists determined to “wait ’em out.”

If your answer is that each of these involved failed attempts at change, you’re correct. But why did they fail? I believe a lack of “situational awareness” is to blame. This term, often used by the military and homeland-security professionals, refers to a person’s ability to integrate input from a variety of sources in order to form a clear understanding of the environment and plan future actions.

Why does situational awareness matter? In short, leaders who lack situational awareness usually fall far short of their goals. And when one of your goals is to lead a major change effort, poor situational awareness can be fatal. Here’s a classic recent example:

On June 10, 2012, the University of Virginia’s Board of Visitors announced that UVA President Teresa Sullivan had resigned. The primary reason initially offered: “philosophical differences.”

University faculty and alumni were stunned. Sullivan was well regarded by most faculty and numerous alumni. The university wasn’t in any sort of a crisis. So, why was Sullivan, UVA’s first female president, forced to resign after less than two years on the job? Helen Dragas, rector (chair) of the board, soon offered additional explanations–a need for bold change, for “strategic dynamism,” the importance of getting into online education. None of it was convincing.

Then came some leaked emails and off-the-record comments from university insiders, all of it damning. Sullivan had received only one informal performance review prior to her firing (which included the comment that she was a “good, not great president”). The board had never given her any warning of major discontent. And it turned out that the board had never met as a body to make the firing decision; Dragas had garnered the votes in one-on-one talks with individual board members.

All of this led to a firestorm of protest from faculty, alumni, wealthy donors and elected officials. On June 26, the board reversed itself and reinstated Sullivan.

Some people thought the matter was settled. But, this past December, UVA was put on warning by an accrediting panel that said the board may have violated governance rules in attempting to force Sullivan out. And UVA found itself back in the headlines last month, when a Washington Post article documented continuing tensions between Dragas and Sullivan, including the fact that the rector had given Sullivan a list of 65 goals to accomplish by the end of this school year!

Why do intelligent, accomplished people make colossal mistakes, such as firing a respected leader without a meeting of the board, without first giving the leader a clear message that she was in trouble, without providing stakeholders and the public with a credible rationale? Why would an experienced leader like Helen Dragas attempt to micromanage the president of an institution that continues to be one of the jewels of public higher education?

There are many theories floating around to explain these mysteries, but I believe the UVA fiasco was primarily about a leader who has no understanding of situational awareness. Dragas may well see herself as engaging in a righteous fight to save UVA’s excellence. Let’s assume the best of intentions. The way she and her board supporters have acted on their concerns, however, reflects extraordinary tunnel vision. Like the three examples in our pop quiz, Dragas and some leaders on the board paid no attention to the organization’s culture. They didn’t learn how change works at their institution, nor did they check in with key organizational stakeholders to share their change plans and get reactions. They all lacked situational awareness.

Every leader can develop situational awareness. It’s not a sophisticated skill set. Rather, it requires an openness to a variety of perspectives from internal and external stakeholders, an understanding of the organization’s culture and recent history, and a willingness to change plans based on these insights. Maintaining good situational awareness is critical to effective leadership.

The Life-Saving Power of Crowdsourcing

It’s hard to imagine a better demonstration of its potential than the worldwide volunteer effort that helped rescue thousands of people after the earthquake in Haiti.

“The future is already here–it’s just not very evenly distributed.” There’s a good deal of truth in science-fiction author William Gibson’s observation. One of the most interesting and powerful aspects of our future–a tool that has the potential to take us a long way toward distributing information to where it can do the most good–is the phenomenon known as “crowdsourcing.”

The use of crowdsourcing–inviting large numbers of people to help solve a problem or make a decision via the Internet–has exploded as creative problem-solvers have found new ways to exploit its power. Most of us are familiar with Wikipedia, the online encyclopedia, which relies on the public to create and edit its content and has fewer than 90 paid employees. Open-source software is another example: Thousands of people with programming skills freely spend their time joining communities that form to develop and improve it.

Government agencies are moving quickly to make the most of social media for crowdsourcing. The Los Angeles fire department, for example, uses Twitter to gather crucial information from residents. People who spot fires tweet the LAFD, sending real-time information that can help save lives and reduce damage.

But one of the most amazing examples of how crowdsourcing can save lives occurred after the January 2010 earthquake in Haiti. Tens of thousands–possibly hundreds of thousands–of people were killed, another 300,000 were injured and a million were left homeless. Relief organizations mobilized to rescue the living and provide for basic needs. Less well known are the efforts of several thousand people spread around the world who were using an open-source, Web-based platform called Ushahidi to find and save thousands of people buried in the rubble.

Ushahidi, Swahili for “bear witness” or “testimony,” was created by some techies during the post-election violence in Kenya in 2008. They were trying to track and map where the violence was occurring by crowdsourcing–mapping the information sent by thousands of people on the ground. Those who managed the Ushahidi site created a map of Kenya and posted the coordinates of each attack. First responders from government and non-governmental organizations found the site invaluable in helping them save lives and care for the injured.

By the time the earthquake hit Haiti, Ushahidi had become a sophisticated tool, integrating Twitter, Facebook, smartphone apps, texts, blogs, YouTube videos and other sources. The Ushahidi-Haiti platform was launched within hours of the earthquake by Boston-area volunteers led by Patrick Meier, one of Ushahidi’s creators. Meier trained some friends to help him update the map. They trained others, who trained others, and within the first week 100 people were using Ushahidi to map the locations of people needing help, buildings about to collapse and other information vital to emergency workers. After two weeks, another 100 people, located around the world, were trained and contributing vital information. And Meier knew almost none of them!

A texting short code (4636) was dedicated for incoming messages about the quake. Witnesses texted 4636 to report what they were seeing or experiencing. If the message was specific–“Someone is trapped in a building located on Border and Smith,” for example–a trained volunteer would map the GPS coordinates on the Ushahidi site, which rescue teams used to locate victims.

But how could people on the ground in Haiti communicate with the outside world, given the devastation? Few Haitians had land lines, but an estimated 70 percent had access to a cellphone, and many of the cell towers wiped out by the quake were rebuilt in a matter of days. Soon, survivors and relief workers were texting to 4636.

Twenty-five days after the earthquake, Ushahidi-Haiti had mapped about 2,500 reports. The United Nations, the U.S. Coast Guard and U.S. Marines were using these maps to focus their relief efforts. In one email, a Marine who worked on the Haiti rescue effort wrote, “I cannot overemphasize to you what the work of the Ushahidi/Haiti has provided. It is saving lives every day. … You are making the biggest difference of anything I have seen out there in the open source world.”

When you think about the implications of crowdsourcing tools like Ushahidi–hundreds or thousands of people who don’t know each other volunteering to work on a common challenge, freely sharing information and operating with no formal organizational structure–it’s hard to argue with William Gibson’s assertion. The future is, indeed, already here. And crowdsourcing is an important and promising part of that future.

Making the Novel Seem Familiar

Most of us are all too comfortable in our habits. The lesson for leaders in an era of change: Make the novel seem familiar.

I just finished reading “The Power of Habit,” a wonderful book that’s changed the way I look at many routines in my work and personal life. The author, Charles Duhigg, decodes why we are so reliant on multiple habits each day, how those habits help our brains and what we can do to change habits when needed.

In an age that requires organizations to change and adapt frequently, leaders continually look for ways to make their organizations more nimble and flexible. But as Duhigg makes abundantly clear, most individuals crave the comfort of habits, including those that are bad for us. How do effective leaders address that challenge?

Duhigg cites an instructive example from history to answer this question:

In the aftermath of the Dec. 7, 1941, attack on Pearl Harbor, our nation had to become prepared for the war effort. This involved a genuine transformation throughout the country, one that touched everyone’s daily life. Gas was rationed, people recycled, they created “victory gardens,” and our diets were affected because most of our meat supply went to the troops. Americans who loved steaks and pork chops soon found them in short supply; they had to find other ways to get their meat fix, like eating liver, tongue, hearts, intestines and kidneys. But government officials were very concerned that Americans would rebel at the notion of eating these organ foods, and would soon become starved of protein.

A group of leading social scientists studied the problem, and their recommendation was simple: make the new foods seem like the old ones. That is, prepare animal organs look, smell and taste just like the meat that we knew and loved. So the government produced easy-to-use manuals for homemakers, filled with recipes using liver and kidneys that tasted like good old beef. These efforts home paid off, most Americans willingly adjusted, and by the 1950s some organ meats had actually become status symbols.

The lesson for today’s leaders: dress the novel in old clothes — make it seem familiar. Duhigg isn’t talking about using spin and manipulation to fool people. Rather, he shows how to meet our brains’ needs for the familiar by making a new product service seem similar to what we already know.

So, how can we make the new seem familiar when leading organizational change? Consider the following:

  • Rehearse for the unusual. Successful sports coaches put their players through drills to prepare them for a variety of situations that occur only occasionally: how the football team will move down the field in its “two-minute offense,” or what the basketball team will do when it has the ball with 10 seconds left and it’s down by two points. These drills help the players feel like they’re in familiar territory when the situation arises during a game. The military and local first responders also excel at such training.


  • Remind people of a past success. Some change leaders ask employees to recall when they have done something in the past that was similar to the current change. For example, I once saw a state agency head introduce a new HR process by noting a previous process change in one division of the organization. “That process is working beautifully now; it took a while, but we pulled it off, and our customers love it. So we know something about changing processes. …”


  • Tap a core competence. Some leaders and managers create a sense of familiarity by showing how one of the organization’s core competencies can be used to implement change.  For instance, many state and local government emergency management agencies have core competencies in planning, communications, and rapid response. These same skills can be critical when implementing  change initiatives. Ask some emergency management staff to take key roles in the change by leading the planning and communications teams.


  • Engage familiar people. Some organizations have brought back former (and successful) leaders to take over the reins during a crisis. That’s what Starbucks did when it lost its edge and brought Howard Schultz back as CEO in 2008. And that’s what the U.S. Environmental Protection Agency did in 1983 when the agency’s reputation was seriously compromised: It brought back its founding director, William Ruckelshaus, a man known for his integrity and dedication to the EPA’s mission.

Engaging familiar people, of course, can include those who already work for your organization when leading a change. Identify a few informal leaders, involve them early in the change planning and see if they’ll take responsibility for one part of the change.

  • Use familiar language. Robert Kennedy once noted that “everybody is in favor of improvement, but mention the word ‘change’ and you immediately make enemies.” Language has a powerful impact on how people perceive their world, so think carefully about the language you use when describing the change. I once consulted with a fine local government department head who had named one of his change projects “Maintaining our World-Class Edge.” That might have worked if most of the employees thought that the agency was functioning extremely well. Alas, many of the staff thought that their agency was functioning poorly, and the title resulted in a proliferation of Dilbert-style cartoons. On the other hand, the Federal Aviation Administration’s strategic plan is called “The Flight Plan.” Because FAA employees take great pride in their agency and its accomplishments, the term “Flight Plan” has a very clear and positive meaning to them.


  • Note that not everything will change. When managing a transition, effective leaders point out what won’t be different as well as what will. If employees will retain their pay grade and titles, if they’ll need the same skills to do their work or if they’ll remain in the same unit, say so. That helps put many people at ease.

And here’s one final thought. You can use Charles Duhigg’s insight — make the novel seem familiar — to build your workers’ confidence about managing change. If your organization has been sailing through turbulent seas in recent years and it’s handled the ups and downs well, refer to that experience and the employees’ resilience. Telling your associates that “we’ve been here before, we know how to handle this” is both honest and reassuring. It suggests that the staff has developed a new habit — the habit of change.