It is essential to create and articulate a vision so your organization will understand the reason for change. Although there are notable historical examples where populations have blindly followed leadership usually to the detriment of society, in most sophisticated organizations particularly those that involve physicians, it is absolutely necessary to articulate the reason for change. Change can be particularly difficult if it is not clear where the organization is headed. The vision should be simple, concise, clear, and easy to articulate. Examples might be: our goal is to move into the top ten in NIH rankings, or we plan to grow our clinical volume by 20 % over the next 3 years, or due to a loss of a major insurance contract we plan to reduce expenses by 10 %. There may be dozens of sub-themes that are required to accomplish each of these goals. However, the overall objective should be transparent and clear to all.

The vision should be widely dispersed and repeatedly emphasized using a variety of venues. Restating the vision or strategic plan at meetings, in conversation, or through print will lead to a widespread understanding of the overall direction of your organization. To reinforce the vision, there are companies that produce laminated pocket cards with a concise summary of the organization’s goals. For reasonably sophisticated groups this approach may be unnecessary. However, one should at any time be able to stop a member of your organization in the hallway, ask what are the organization’s top three goals, and anticipate the same concise answer from all. Asking an organization to change without providing a clear and logical goal can be a recipe for failure.

Although debatable, I believe that most goals, particularly the positive ones, should be aspirational, higher than what you predict can ever be achieved. On the positive side, if you are leading physicians, you are endowed with an organization of overachievers. Moreover, if you plan for a home run there are few that would be disappointed with a stand-up triple. That said your goals should not be unrealistic. If the target is so unachievable that it can never be reached, no one will ever try. It can be frustrating to fall significantly short of your goal, especially in an organization where the constituents are accustomed to success.

The vision or goal that you create should be logical and sensible. The loss of an important insurance contract has reduced the organization’s revenue by 10 %, thus the organizational budget must be diminished accordingly. Although this seems a relatively straight forward and persuasive rationale for cutting costs, the devil is in the detail. For example, there is a common belief that under duress, organizations can manufacture money or that there are secret caches that can be called up from reserve. The other common argument made during budget reduction discussions, is that my department because of its importance to the organization should remain budget neutral while other less important departments make cuts. All of these complexities aside, it is widely understood that all organizations need to balance their budget, thus external financial pressures make a sensible argument for internal fiscal reform. Alternatively, it is easier to create vision around positive rather than negative goals. Why would you not want to be top ten in NIH rankings or who would not want to grow their clinical volume? These goals are “mom and apple pie”. In a broad sense it would be almost unpatriotic to argue against these types of goals. Regardless of whether the organization’s goals are positive or negative, they need to be concise, logical and reasonable in order to gain wide spread acceptance.

With rare exception, every leader reports to an even higher level of leadership. The hospital CEO reports to his or her board and the Dean reports to either a board or the Chancellor. When instituting change, particularly, changes that are controversial, it is essential that leadership be supportive. If your constituents are not satisfied with the changes that you proposed there is almost absolute certainty that your leadership will become aware and even involved. Thus, it is essential that there be upward communication before the change is implemented. Your leadership will feel “blindsided” if the first time they learn about a controversial decision is when they are approached by someone from your organization who is negatively affected. How often you need to preemptively communicate your decisions with leadership can vary. The most relevant factor will be your relationship with these individuals. Is there mutual trust? Will your leadership support you even if they disagree with the decision? Early in your leadership role, more is likely better when it comes to communication.

In addition to gaining the support of your leadership it is important to (1) gauge the strength of their support, (2) measure their individual fortitude or ability to withstand controversy and (3) assess the complexity of their and your political environment. For controversial decisions, your leadership must be completely aligned. Moreover, they must have the strength to provide firm support regardless of the level of controversy. Lastly you need to understand the larger political environment. Your leader may or may not, at this specific juncture, have the necessary political capital to help implement your change.

It is equally important to gain the support of other key individuals in your organization. This would include individuals who have significant institutional influence or who are directly or peripherally affected by the proposed change. For example, if you are the Chair of Surgery, other leaders that are often affected by your decisions include other Department Chairs, the institution’s Chief Medical Officer, the Board of Trustees, other medical school or university leadership, legislators, etc. Communicating with these individuals, whether it be to provide information or persuasion, will enhance the likelihood of your initiative’s success. For controversial changes, it is absolutely essential that leadership and key constituents be solidly behind you.