My View - Leading an upward spiral

VIEW - Jono Hoogerbrug - GP, Clinical Informatics Director and Host of Clinical Changemakers Podcast

In healthcare we love to say: "We are building the plane while it's flying." It's a badge of honour and a nod to the complexity of keeping a health system running while simultaneously trying to improve it. But there is an experience we have all felt before yet often avoid putting voice to, what happens when the plane is in a nosedive?

Picture this. You are on a plane and you are rocked by sudden turbulence. You exchange glances with the air crew. They look surprised. Then comes a bang and flames from the engine. Silence fills the cabin. The crew just stare at each other. That silence tells you something serious is going on. Now you hear them speak, blaming the engineers, the pilot, air traffic control, and finally each other. Everyone sits still, slowly accepting the inevitable.

This metaphor helps to illustrate Professor Rosabeth Moss Kanter’s description of what can happen in organisations, a downward spiral that starts with a blow to an organisation's fortunes. The blow shakes its culture, causing cracks to appear. Blame begins, and communication stops. People naturally retreat into silos. Isolation entrenches trust breakdown and a sense of helplessness. Before long, the organisation has accepted this as the new, diminished normal.

If you have worked in healthcare, you have probably experienced this before.

Pulling up

When in freefall, a plane doesn't gently level itself out. It takes deliberate, sometimes drastic intervention: a leader making a decision and committing to a new heading. This purposeful act changes the momentum, empowers team members, and sparks new initiatives. The goal is not simply to arrest the decline, but to create an upward spiral: restoring people's confidence in themselves and in one another.

Kanter points to three interconnected drivers that make this possible: promoting trusted dialogue, sparking collaboration, and inspiring and empowering the people who do the work. Each of these deserves attention not as abstract principles but as practical commitments that leaders can act on today.

Promote trusted dialogue

When a team is spiralling, honest conversation is the first casualty. People stop saying what they think. Problems go unreported. Concerns are shared only in corridors and car parks.

Professor Amy Edmondson of Harvard Business School has spent decades studying this phenomenon through the lens of psychological safety,  the belief that your environment is safe enough to take interpersonal risks. This means that free, fair, and sometimes fierce discussion can be had without fear of punishment or humiliation. Its application in healthcare has shown it can reduce medical errors, improve team performance, and promote quality improvement. Two practices can make it possible. Situational humility - acknowledging what we don't yet know - and proactive inquiry: "We. have never been in this exact situation before, so what should we look out for?" 

Dr Stephen Swensen, formerly of Mayo Clinic, extends this through to their approach to enterprise listening. Through systematic listening across their organisation, Mayo found that five leadership behaviours; appreciation, understanding, mentorship, transparency, and inclusion, are the most powerful determinants of staff wellbeing, even more than salary. At Mayo, this has been operationalised through democratically elected clinical leaders, cyclical term lengths, and a deliberate culture of listening and then acting. Leaders are empowered not only to ask, but to act on the question: "What makes for your best day at Mayo?"

Spark collaboration

The organisation chart is often pointed to as the place to understand how an organisation works, and a large assumption comes along for the ride, that structure equals collaboration. Everyone knows this does not actually tell you where the work gets done.

Professor Ingrid Nembhard of the Wharton School points out: "We have done many things structurally to improve quality... but have not seen the gains for the level of investment." Real activity does not happen through reporting lines alone. It happens through trusted informal connections and through the champions who bridge disconnected teams.

Leaders pulling out of a downward spiral need to find and support these influencers - the people who know everyone, who translate between departments, who make things happen despite the org chart. This means investing in leadership and relationships that drive coordination and treating human networks as infrastructure, just as critical as IT systems or care pathways.

In practice, this might mean mapping where collaboration actually happens rather than where it's supposed to, protecting time for cross-team connection, and recognising the informal leaders who hold networks together.

Inspire and empower

There is an assumption in healthcare that inspiration comes naturally, that because the work is inherently meaningful, people will find purpose in it. But in reality, measurement systems and administrative burden can actively drain that meaning from the work.

Dr Raj Behal of Amazon One Medical offers a useful reframe through Clayton Christensen's "jobs to be done" framework. Instead of assuming we know what motivates our teams, go and ask them: what is the job you are really trying to do? Health is a means to an end. A team member doesn't want to finish their discharge summary, they want time to provide the best care for their patients.

This opens a more honest conversation about how we approach measurement and success. Are our metrics capturing what matters to the people doing the work? Are they helping or hindering? As the saying goes, not everything you measure matters, and not everything that matters can be measured. 

When we align our systems with what teams are actually trying to achieve, we unlock a different kind of energy, one that comes from feeling that the organisation is working with you, not against you.

Back to our plane

The nosedive doesn't have to end in a crash, however recovery demands space for leaders to make deliberate decisions and to change the trajectory. It requires rebuilding trusted dialogue so people can speak honestly, investing in the human networks where collaboration actually happens, and creating the conditions where meaningful work can thrive.

Imagine looking across the cabin again. This time the crew are talking, clearly and calmly. Someone takes the controls with confidence. Others move to their positions with purpose. They have trained for this, they trust each other, and slowly, deliberately, the nose begins to lift.

That is the upward spiral, and it starts with a leader's decision to act.

If you want to contact eHealthNews.nz regarding this View, please email the editor Rebecca McBeth.

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