Leading upstream in health

While this juggle is not new for any leader, leading in health can be particularly complex. Health, by nature, focuses predominantly on ‘downstream’ activities, reacting and responding to people’s current and emerging health needs. Leading in health requires an ability to readily adapt to changing community needs and expectations, incorporating exponential technology disruption and responding to broader societal and environmental challenges (including global pandemics, natural and anthropogenic disasters). At the same time, from an organisational perspective, health leaders also manage complex industrial and professional arrangements, staff fatigue and burnout, intricate rostering requirements, funding models, service implications and governance responsibilities.

Leaders in health often find themselves pulled into urgent, reactive activity at the expense of moving ‘upstream’. The pull downstream is strong – and humans naturally want to swim there! It is our nature to focus on the tangible, concrete, immediate, urgent, visible need; it’s hard-wired into our brain. Despite this, the role of leaders is not only to solve downstream problems, but to build a system that addresses issues upstream and creates a sustainable health system for the future. However strong the current, if leaders aren’t able to spend some time upstream, they miss the opportunity to develop and refine strategies to address these complexities.

But what does upstream mean – and what does it look like? Leading upstream means anticipating and preventing problems, rather than simply solving them as they arise (and sometimes solving the same ones repeatedly). It’s not easy to achieve and requires working against strong external forces and potentially our own internal identity, comfort and capability.

“The postmortem for a problem can be the preamble to a solution.” Upstream: How to solve problems before they happen, by Dan Heath

Upstream and downstream

Our organisations need to be functioning effectively both upstream and downstream – each is equally critical. In a health context, downstream might be a clinician providing safe, quality care to a patient. Ultimately, of course, that’s the purpose of the organisation. However, leadership strength – and hence organisational resilience – lies in the ability to move out of the downstream, even for short periods. That means making space to anticipate and strategise (i.e. working upstream).

As crises hit, such as COVID-19, it’s natural to be drawn downstream; to become immersed in frontline problem-solving. But while that might be necessary in some moments (or for short periods), the key for leaders is to extricate themselves; to step away from some immediate problem into preventing those that have not yet emerged. Solving one challenge upstream could prevent dozens of downstream problems, removing barriers, frustrations and inefficiencies for your people to focus on what they do best.

Working downstream vs working upstream

Working downstream:

• Immediate and urgent

• Tangible and concrete problems

• Easier to see and measure benefits

• Feel the immediate 'pain' of the problem

• Narrow focus

• Fast response

• More operational

• Solves problems in the moment

• Short-term priorities

• Personally provides service delivery

Working upstream:

• Important over urgent

• Complex and ambiguous problems

• Benefits realised long-term

• Prevent or reduce future pain

• Broad focus

• Considered response

• More strategic

• Solves root cause of problems

• Long-term priorities

• Coaches others to deliver

Example: Patient flow

When the Emergency Department is full, ambulances are being ramped, and wait times for patients are increasing, staff on the ground call on their leaders to help.

When you repeatedly focus on resolving immediate patient flow issues, you're staying downstream and preventing your staff from learning to solve this in the future and creating an entrenched cycle of working downstream.

Your people are (hopefully) capable and competent to resolve immediate challenges (with your help at first). It's your job to equip and trust your team to solve the immediate need (including once-off/rare issues), which creates space and time for you to collaborate with your peers across the organisation, working upstream to create holistic, long-term solutions for whole-system problems.

Why is it hard to spend time upstream?

There’s a lot keeping us downstream – and how we measure success as individuals and as health organisations plays a large part. From the individual perspective, the pull of our teams, our sense of responsibility, and our need to be seen to be delivering all strike at the core of our being. In fact, our perceived career trajectory is often predicated on success downstream – doing well on the frontline precedes a move into leadership.

From an organisational perspective, success in health is often measured by the ability of teams to respond, such as Emergency Department wait times, inpatient length of stay, occasions of service, clinical indicators and outcomes, surgical and outpatient wait lists, ambulance ramping and vaccination rates. Additionally, what gets measured, usually gets attention (and funding) since budget allocations are heavily influenced by key indicator activity and performance. Comparatively, the upstream is harder to define and measure, so usually draws less attention.

This often means that leaders don’t feel supported to do upstream work – despite them feeling like it may be the right thing to do. This creates a double bind unless they have the confidence to do upstream work for little appreciation. However, their experience is different if they are working with other leaders who recognise and value the importance of working upstream – and together they drive the organisation to think more strategically.

So, how can we redefine our role and identity as leaders who spend time leading upstream? Moving upstream means pulling back (even briefly) from delivery; realising that you can’t solve systemic issues one patient or problem at a time. It requires you to relinquish the dopamine reward (i.e. boost of the ‘happy brain’ chemical) of solving individual problems – instead of enabling and empowering your team to deliver, solve problems and innovate. People, systems and our own nature will never make it easy to shift, but it’s what our organisations and communities need.

Where are you leading?

All leaders will spend time both upstream and downstream. We all need to be connected to service delivery while still creating space to think, plan and solve upstream.

The ideal balance of time in each stream depends on your role – in team leader roles there’ll be a stronger focus downstream; in middle management roles, more of an even split; and in senior leadership roles, upstream should be the majority of time and focus. 

As a rule of thumb, you’ll likely need to spend some time downstream – recruiting, coaching and building your team – so they’re in great shape to handle the downstream when you spend time upstream.

“If you think about the way we conceive of heroes, our schema of heroes, we’re thinking about people who rush in when there’s an emergency, the firefighters who put out the flames in a burning building, or the lifeguard who jumps in the pool to save the drowning kid, or the policeman who comes to fight off a burglar... an even better hero is not someone who saves the day but keeps the day from needing to be saved…” – Dan Heath

Signs you might be spending too much time downstream

• Your diary is fully booked with back-to-back meetings

• You feel you have little control over your diary, your time or your focus

• There are gaps in your team, but you’re too busy to recruit and the process is too onerous

• Decisions are made in silos, with engagement or consultation carried out as an afterthought

• It feels as though you’re just sprinting from one urgent priority to another

• Risks get to a critical point before they get managed or resolved

• Financial performance is often a surprise and doesn’t necessarily align with proposed budgets

• A lot of time and focus is spent on grievances, mediation, work cover claims and conflict management

• Your team are hesitant to make decisions and defer to (or wait for) you

• It feels as though you’re bogged down in service delivery

• You have a long list of things you’d like to get to… but can’t seem to find the time

What’s the impact on your team or organisation when you spend too much time downstream?

• The automatic response is to maintain the status quo – to do what we’ve always done

• People become more siloed and fractured

• People feel exhausted, burnt out, helpless or unmotivated

• There can be a punitive, reactive culture of blame

• Teams are heavily reliant on the leader to make decisions, get traction and manage the work

• People and teams aren’t fully performing because there isn’t enough time for coaching

​​Signs you might be spending enough time upstream

• Considered trade-offs are made to focus on strategically aligned priorities

• You have time carved out in your diary for slow thinking, strategy and planning

• Decisions are made in line with clear principles and in the appropriate forum, after early and genuine engagement, with a commitment to hearing diverse perspectives

• Your automatic response is to explore options, challenge what we’ve done before and co-create a new way

• Innovation and improvements ‘bubble up’ rather than being ‘rolled out’ centrally 

• There’s a strong focus on, and investment in, people, culture, wellbeing and leadership

• Even in the face of challenge or pressure, the team has a sense of strength and resilience to flex as developments unfold

• Risks (and potential risks) are monitored, managed or mitigated at the early warning signs

• Investment and financial decisions are made to maximise opportunity, make savings – and with the future (next 10 years) in mind

What’s the impact on your team or organisation when you spend enough time upstream?

• People’s identities are aligned with the organisation’s purpose and values

• Culture is supportive, adaptive, resourceful and motivated

• Teams are self-organising, autonomous and can operate well when the leader is absent

• People and teams take accountability to perform and work to their strengths

• People feel focused, optimistic and energised

Barriers to working upstream

The pressures that prevent upstream leadership are many and varied – drives for efficiencies, safety and quality, innovation, equity and access, a lag in systems, processes and funding models and more. Such barriers are huge – that much is undeniable – but if we stay mired in reactivity, the problems will keep coming and the bigger picture solutions will move even further from our reach.

To tackle problems at their root, we actually have to challenge the human drive to ‘rescue’ – we need to move from cure to prevention. It’s harder to measure and is lacking in traditional ‘glory’, but it delivers the best results.

Population health and prevention

We’re asking our health industry to provide health services to a growing and ageing population who are experiencing increasing rates of chronic disease and obesity – and in the current models, that’s recognised by many as unsustainable. 

One critical upstream response to this, population health and prevention, is often alluded to in the strategic plans of hospital and health services’, but many health organisations struggle to fund, focus and deliver on these in a meaningful way (despite their best intentions and efforts). If we took more of a systems view to the health of the population, we’d prevent hospitalisations and outpatient visits, keeping people healthier and living a better quality of life. This is, increasingly, a focus across the care continuum, but more could definitely be done.

Steps to moving upstream

Changing the way you lead means creating space to pull back upstream. But having space to reset will never be gifted to you – carving out even small moments for upstream leadership and your teams and organisation will reap the rewards. Practically, this can look like setting aside time for strategic thinking, planning, goal setting, making trade-off decisions and empowering your team.

Front line leaders

• Choose to coach rather than to solve

• Understand that your prior identity as a ‘doer’ or ‘deliverer’ is no longer relevant – if you hang on to it, you’ll hold yourself and your team back

• Build capability in your teams 

• Listen to your people and encourage innovation and improvement

Middle managers

• Develop the leadership skills of your team (frontline leaders who report to you)

• Build strong relationships up, down and across the organisation 

• Adopt a positive performance approach – recognise and celebrate high performance, and quickly and kindly address any gaps

• Identify patterns and solve recurring problems (particularly those that might sit at the edges of your remit and affect cross-functional areas – take a systems approach)

• Streamline processes, procedures and practices – make it easier for your people!

Executives and senior leaders

• Communicate the strategy and priorities – clearly, consistently and repeatedly

• Empower your leaders to make decisions at their appropriate level

• Focus on people, culture and values

• Prioritise strategy

• Break down silos by working across the organisation, connecting the dots and involving multiple disciplines in solving complex problems

• Create opportunities for thinking, creating, exploring

• Ensure succession planning is done in a considered, coordinated way across the organisation.

Five powerful questions to ask yourself to move upstream:

You’ll rarely be invited to move upstream, so if you don’t make it happen then you’ll remain downstream. It’s a constant juggle to create this time and space; however, the urgent will trump the important if you don’t. Having support around you can help with this shift – if your leader and team aren’t aligned then find peers or an external network to provide this support. There are also some powerful questions you can ask yourself to stay on track as you paddle upstream.

1. What am I doing that I could delegate or coach someone else to do?

2. Where do I need to focus so I make the most of my time today?

3. How can I remove barriers and get out of my people's way?

4. How could I solve a recurring problem so it's a sustainable fix?

5. How could my team focus their efforts to make a positive impact for the whole organisation (for years to come)?

As a final thought, in his book, The One Thing, Gary Keller suggests asking yourself, “What’s the one thing you can do, such that by doing it, everything else will be easier or unnecessary?” Asking yourself these questions will help you stay focused on what’s important and turn intention into action.

Whenever you feel the downstream pull has prevented you from spending time upstream recently, think of what you could do differently. Could you improve workflow for your teams, innovate to improve health outcomes or reduce the cost of delivery? Your investment upstream is likely to benefit both your teams and the communities they serve.