DDHA 8113 Week 3 Adaptive Leadership Case Analysis Example

Predicted First, Checked Second: Adaptive Leadership Applied to England's Decision to Replicate the Michigan ICU Program, Keeping the Finding the Model Did Not Expect

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Walden University

DDHA 8113: Advanced Concepts in Healthcare Leadership

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Month Day, Year

Predicted First, Checked Second: Adaptive Leadership Applied to England's Decision to Replicate the Michigan ICU Program, Keeping the Finding the Model Did Not Expect

The Case and Why It Suits This Test

In 2006, a statewide program in Michigan reported a large drop in central line bloodstream infections across more than 100 intensive care units, from a median of 2.7 infections per 1,000 catheter-days at baseline to zero within three months of implementation, with reductions of up to 66 percent sustained for 18 months (Pronovost et al., 2006). Health leaders in England then decided to replicate the program across their own intensive care units under the name Matching Michigan. That decision suits a test of a leadership model for three reasons. It is documented in published evaluations rather than in a single organization's account. It involved leaders choosing how to carry a successful program into a new context, which is exactly what leadership models claim to explain. And its outcome is known, which means a model can be asked what it predicted and then checked.

This paper applies adaptive leadership to the replication decision. It states what the model implies before turning to the record, and then reports both the parts the record confirmed and the part it did not.

The Model

Adaptive leadership, as Heifetz and Laurie (1997) set it out, separates problems that can be solved by applying existing expertise from problems that require the people involved to change their own values, habits or relationships. The first kind can be handed to experts and solved with procedures. The second kind cannot, and a leader who treats it as the first kind produces what the model calls work avoidance: people comply with the visible requirement while the underlying practice stays the same. The model asks leaders to keep the group's attention on the hard question, to manage the level of distress so people neither shut down nor ignore the problem, and to return the hard work to those whose own habits have to shift, instead of solving it on their behalf. Corazzini et al. (2015) applied the framework to culture change in nursing homes and argued that the distinction between the two kinds of challenge helps explain why some changes stall after training is delivered.

What the Model Implied Before the Record

Applied to the Michigan program, adaptive leadership would read the original success as mainly adaptive work. Checklists and line insertion carts were the technical part. The harder part was changing who could stop a physician mid-procedure, how nurses and doctors spoke to each other and whether units treated infections as preventable. Dixon-Woods et al. (2011), in an account of why the Michigan program worked, described mechanisms that fit this reading closely: a networked community that exerted pressure through peers, a reframing of infections as a social problem rather than a technical one, data on infection rates used as a disciplinary force, and firm requirements described as hard edges.

From that reading, the model implied three predictions for England. First, units that adopted the program's visible elements without the relational work would show compliance without changed practice, and these would be the majority, because replication tends to carry tools more easily than relationships. Second, a minority of units with local leaders who surfaced conflicts and gave the work back to frontline staff would change substantially. Third, where national authorities had previously imposed infection targets from above, the program would meet resistance, because staff would read it as another instruction rather than an invitation to change their own practice. A fourth implication follows from the model's logic: improvement in outcomes should track the adaptive work, so units that changed little should improve little.

What the Record Shows

The published evaluations support the first three predictions. An ethnographic study of the English program interviewed 98 staff and observed 19 units, 17 of them participating, and found that one unit transformed its practices and culture, five boosted efforts already under way and eleven made little change (Dixon-Woods et al., 2013). The same study found that earlier national infection control policies, perceived by some staff as top-down and punitive, undermined engagement and made it hard to persuade participants that the program was needed. It also found that local leaders' success in building consensus and coalitions influenced how much each unit changed. These findings match the model's expectations about work avoidance, the minority that changes and the cost of prior imposition.

The Part the Record Embarrassed

The fourth implication did not hold. The outcome evaluation found that infection rates in adult units fell from 3.7 in the first cluster to 1.48 per 1,000 catheter-patient days over 20 months, and its authors concluded that the drop was likely part of a wider secular trend of improvement in healthcare-associated infections across the English system (Bion et al., 2013). Rates fell in units that made little change in response to the program as well as in those that transformed. The ethnographic study put this in a memorable way: the same visible pattern of compliance can arise through different underlying routes, and program participation is only one of them (Dixon-Woods et al., 2013).

This is awkward for adaptive leadership. The model treats authority-driven, technical solutions as unable to resolve adaptive problems, yet in England a period of national targets, mandatory surveillance and infection control policy, the kind of top-down approach that the model regards with suspicion and that staff described as punitive, coincided with falling infection rates regardless of how much adaptive work each unit did. Two readings are possible. One is that central line infection was less adaptive a problem than the model's reading of Michigan suggested, so that well-specified procedures, enforced firmly, could do most of the work. The other is that national pressure did adaptive work of its own, changing what units regarded as acceptable, without anyone describing it in those terms. Either way, the model's implication that outcome improvement would follow the adaptive work alone was wrong in this case.

What a Leader Should Take From This

For a service line director deciding how to spread a practice across hospitals, the case gives adaptive leadership a mixed report. Its account of why replication carries tools more easily than relationships held up, and its warning about prior impositions souring engagement was borne out. Its implicit dismissal of firm, authority-backed requirements did not hold up. The Michigan program itself used hard edges, and the English outcome suggests that firm requirements can contribute to improvement even when the relational work is uneven. A leader using the model would be wise to treat the technical and adaptive parts of a problem as complements, and to resist the model's tendency to treat authority as a sign that leadership has failed.

Conclusion

Adaptive leadership predicted that England's replication of the Michigan program would produce mostly compliance without change, a small number of transformed units and resistance shaped by earlier top-down policy, and the published record confirms each of these. It also implied that outcomes would follow the adaptive work, and that implication failed: infections fell across the system along several routes, including firm national requirements. The model explains the human side of replication well and underrates what authority can achieve.

References

Bion, J., Richardson, A., Hibbert, P., Beer, J., Abrusci, T., McCutcheon, M., Cassidy, J., Eddleston, J., Gunning, K., Bellingan, G., Patten, M., & Harrison, D. (2013). "Matching Michigan": A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Quality and Safety, 22(2), 110-123. https://doi.org/10.1136/bmjqs-2012-001325

Corazzini, K., Twersky, J., White, H. K., Buhr, G. T., McConnell, E. S., Weiner, M., & Colón-Emeric, C. S. (2015). Implementing culture change in nursing homes: An adaptive leadership framework. The Gerontologist, 55(4), 616-627. https://doi.org/10.1093/geront/gnt170

Dixon-Woods, M., Bosk, C. L., Aveling, E. L., Goeschel, C. A., & Pronovost, P. J. (2011). Explaining Michigan: Developing an ex post theory of a quality improvement program. The Milbank Quarterly, 89(2), 167-205. https://doi.org/10.1111/j.1468-0009.2011.00625.x

Dixon-Woods, M., Leslie, M., Tarrant, C., & Bion, J. (2013). Explaining Matching Michigan: An ethnographic study of a patient safety program. Implementation Science, 8, Article 70. https://doi.org/10.1186/1748-5908-8-70

Heifetz, R. A., & Laurie, D. L. (1997). The work of leadership. Harvard Business Review, 75(1), 124-134.

Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., Sexton, B., Hyzy, R., Welsh, R., Roth, G., Bander, J., Kepros, J., & Goeschel, C. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725-2732. https://doi.org/10.1056/NEJMoa061115