Women In Leadership SAMPLE PACK
Where possible, remove genderidentifying data. Include quantitative information wherever possible. Require adequate representation on short lists. Train anyone in an evaluative position to understand implicit bias. Adjust for bias in recommendations and elsewhere. Examine systems and procedures for unintended bias. Create more transparency and monitoring. Hold people accountable for results.
MERITOCRACY: From Myth to Reality
Our frames of reference and procedures contain implicit biases that devalue women’s contributions and reinforce the privileges of dominant groups. Here’s what to do about it. By Sarah Kaplan
LAST YEAR’S UPROAR over Microsoft CEO Satya Nadella’s statement that women shouldn’t ask for raises, but instead, “trust in karma” for their rewards, has highlighted a tension that exists in corporate and investment communities: we believe that we operate in a meritocracy, but the evidence increasingly suggests that we do not. Instead, our systems for evaluating people and investments are skewed in unintended ways by biases that work against women and minorities. For example, female-led startups find it harder to obtain funding than those led by men; women are often not hired or promoted at the rate of men; and the 2009 passage of the Lilly Ledbetter Fair Pay Act in the U.S. is only necessary because — even in the 21st century — women are not paid equally for the same work. I became interested in the question of meritocracy because of my own research over the past three years, examining the emergence of a new field at the nexus of gender and investing. The leaders of this movement are working to understand how women-led ventures can get equal access to capital and how capital allocation can encourage more equal outcomes for women in organizations. An idea that has come up over and over in the course of my research is that the collective belief in meritocracy is part of the problem. Sharon Vosmek, CEO of Astia — a non-profit organi-
zation focused on helping women participate fully in high-tech entrepreneurship — reflected this idea in a presentation at Stanford last year, describing the high-tech world as, “so captured by the myth of meritocracy… that it has really held back dialogue” on gender. The bottom line: the belief that we operate in a meritocracy takes us off the hook from examining the potential for bias in our evaluations of women-led businesses and women leaders. Some Evidence on Bias
The biases that devalue women are not normally intended at all. Indeed, many of the skewed outcomes for women are produced through supposedly neutral or objective processes. The problem is, the way we see the world is shaped by our frames of reference, and, as Stanford Sociologist Cecilia Ridgeway has pointed out, gender is a primary frame that shapes how we value peoples’ contributions, without us even knowing it. That is why such stereotypes are called implicit biases. Let’s start by thinking about how people are recruited, promoted and rewarded in organizations. In their studies of recruiting processes, Psychologist Rhea Steinpreis and colleagues found that when evaluating identical applications, both men and women prefer to hire a candidate named Brian over one named Karen by a ratio of two to one. These same results have been found for names that are seen as more African American or rotmanmagazine.ca / 3
The paradox of meritocracy is that a belief in it can lead to even more inequality, rather than less.
Hispanic, and for resumes that signal homosexual orientation relative to those that do not, as Rotman Professor of Strategic Management András Tilcsik and others have shown. [Editor’s Note: read our interview with András on page 108 of this issue.] Furthermore, even when the underlying quality of candidates is the same, applications vary. Studies of recommendation letters by anthropologists Frances Trix and Carolyn Psenka show that those written on behalf of female candidates are shorter, more likely to focus on personal characteristics, less likely to emphasize specific accomplishments, and more likely to subtly raise doubts (e.g., “It’s amazing how much work she is able to accomplish, given her family obligations!”) In this case, an equally qualified female candidate might actually appear to be less qualified because her recommendation letter is w eaker. Either w ay, the results are the same: the man is hired more frequently than the woman. Once on the job, the evidence suggests that there are differences in promotions and salary, as well. One of the essential underpinnings of the class action lawsuit against Walmart is the difference in salaries that increases as seniority increases, such that in 2001, female regional vice presidents earned on average 33 per cent less than men of the same rank. Elsewhere, research analyzing how people use performance evaluations to determine compensation shows that women and minorities with equal scores to those of white men receive lower salaries and smaller wage increases. The result: women have to be more qualified in order to get the same rewards. At a recent conference on gender and finance, one of the participants told me: “I feel like my formal education process was a huge disservice to me as a professional, because it was really the only meritocratic environment I will ever be in. When I entered the workforce, I was so used to being rewarded for doing hard work and asking questions that it took me a couple of years to realize that it [meritocracy] wasn’t going to happen.” One might contend that it is the context that leads to these biased results, and that in a more ‘objective’ setting — say, the realm of investing — these effects should disappear. Unfortunately, they do not. Take the venture capital (VC) world of Silicon Valley, which has often been heralded as ‘the ultimate meritocracy’. According to one VC partner, “If you don’t get funded,
it’s because your idea is stupid.” However, people are increasingly questioning why such a ‘meritocracy’ leads to a situation where only six-to-eight per cent of venture capital investment goes to women-led businesses. Is this a supply problem? Indeed, there are fewer women in Engineering programs, and therefore fewer high-tech startups led by women. On the other hand, we can’t ignore the demand side of the problem. Even the women-led startups that do get launched face higher barriers to funding than those started by men. A recent study in the Proceedings of the National Academies of Science by Alison Woods Brooks and colleagues examined nearly 100 startups in live-pitch competitions, and found that male-led companies were 60 per cent more likely to be funded. Perhaps, the argument goes, women start lower-quality companies, and the difference in funding represents a difference in quality. So, in web-based experiments, these scholars presented the exact same PowerPoint pitch presentation, narrated by either a female or a male voice. The result: investors were more than twice as likely to recommend funding the business pitched by the male voice, even though the scripts were exactly the same. The Paradox of Meritocracy
Could it be that the very idea of a meritocratic culture exacerbates unequal outcomes? A series of experiments by Emilio Castilla and Stephen Benard found that organizational contexts that promote meritocracy are most likely to produce non-meritocratic outcomes — such as when men receive higher bonuses than equally-performing women. This occurs, they argue, because the idea of meritocracy gives evaluators ‘moral credentials’ that convince them that they are unbiased, precluding them from being on the lookout for bias. Thus, the paradox of meritocracy is that a belief in it can lead to even more inequality, rather than less. As one Silicon Valley participant in my research said, “Those who are the biggest offenders o f what a m eritocracy should b e are those who are screaming the loudest that there is a meritocracy.” Echoing this, another of my interviewees said about the VC world, “Meritocracies are noble and worthy goals, but they’re absolute myths. The only thing that meritocracy serves in Silicon Valley is as great validation if you’ve made it; it justifies your success. You are just that much smarter than everyone else.” rotmanmagazine.ca / 4
One solution to gender bias is to take gender out of the equation.
If we succeed, we like to believe that it is due to our own merits and, thus, it is in our interest to believe that the system that enabled us to succeed is meritocratic. Indeed, as Jacki Zehner, a former senior executive at Goldman Sachs, reported about its internal research on diversity, “The feeling that the firm was a meritocracy was much more likely to be held by those in the majority [white, male, heterosexual] group. Non-majority members were more likely to say that there were ‘hidden rules’ for success, and that it was harder to get the right opportunities.” Rutger’s Professor Nancy DiTomaso’s rich exploration of race and privilege in the U.S. could be extended to offer some insight about these gender dynamics. According to DiTomaso, “Racial inequality is most often assumed to be the result of racism or discrimination, and providing equal opportunity within a context of individual effort and achievement has been offered as the primary solution.” According to this logic, meritocracy should ‘fix’ problems of racism, because most people are consciously committed to colour- or gender-blindness and to equal opportunity. But this very framing of the issue, she argues, “contributes to the inability of most whites to see the nature of their own participation in the creation and reproduction of racial inequality. Whites assume that other people are racists, but not them. They assume that equal opportunity embodies fairness, but they live lives of advantage—of unequal opportunity.” Thus, she concludes, we can have racial inequality in our society without racism per se. Though the forces at work in sexism and racism are not the same, one could extend DiTomaso’s argument to suggest that explicit sexism need not be present to explain unequal outcomes. Instead, we only need to understand how dominant groups attempt to reinforce privilege — by promoting myths of meritocracy based on equal opportunity. If we lay the blame on overt ‘racists’ or ‘sexists’, we divert attention from understanding the implicit biases built into our own frames of reference and in decision-making procedures that lead dominant groups to reinforce their privilege. Why Progress Is So Difficult
Given that gender is a primary frame that instantly (and subconsciously) shapes our interactions with others, one solution to
gender bias is to take gender out of the equation. When some symphony orchestras switched to auditioning candidates behind a screen — so that judges could hear the musician playing but not see any physical characteristics — the percentage of new female hires increased by between 25 and 46 per cent. This approach may be difficult to replicate in business, where decisions depend on interaction with candidates or leaders of firms seeking investment. On the other hand, research by Roberto Fernandez, Isabel Fernandez-Mateo and others suggests that much of the bias is introduced in the early screening stages of decisions — for instance, those decisions about whether a job or investment candidate should even be in the consideration set. As a result, if ‘gender markers’ can be eliminated from the initial screen, we may see progress. Another fix could entail teaching women to ‘pitch’ better and present themselves better in interviews. This is a central recommendation of Sheryl Sandberg’s best-seller, Lean In, which underpins the discourse around the supposed ‘confidence gap’ for women. Because women are not normally socialized to negotiate on their own behalf, there may be benefits to this approach. On the other hand, research suggests that when women ‘lean in’ and act more confidently, they are likely to be ‘pushed back’. This is consistent with the well-established research that women can be seen as ‘competent’ or ‘nice’, but not both, and that women are penalized for succeeding in ‘male’ tasks. One can almost understand why Microsoft’s Nadella told women not to ask for raises: perhaps he instinctively knows that such requests will not be viewed favourably coming from a woman. Trusting in karma does not seem like a good alternative, but the furor around his comments highlights the dilemma: damned if you do, damned if you don’t. Towards a True Meritocracy
Despite the challenges described herein, there is plenty we can do to get closer to a true meritocracy. Based on my research to date, following are eight suggestions. 1.
WHERE POSSIBLE, REMOVE GENDER-IDENTIFYING DATA. As indicated, it is impossible to avoid direct interaction when making hiring or venture-investment decisions. However, in the
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biased, we can do more to reflect on how that might be shaping our decisions. For example, if someone says that a particular female job candidate ‘has sharp elbows’, we can call that out as gendered and adjust our conclusions; or if someone says that the female CEO of a new venture ‘doesn’t have leadership qualities,’ we should think again.
initial screening to create ‘short lists’, it may be possible to remove names and other gender-identifying information when evaluating candidates. 2. INCLUDE QUANTITATIVE INFORMATION (I.E. GPA OR FINANCIAL PERFORMANCE INDICATORS) WHEREVER POSSIBLE. When there is ambiguity with respect to credentials, members of the dominant group will benefit. Studies have shown that if grade point averages are added to otherwise identical resumes, the bias in selecting the male candidate is diminished. 3. REQUIRE ADEQUATE REPRESENTATION ON SHORT LISTS. Be proactive in soliciting diverse applicants — for jobs, business plan competitions, pitch nights, etc. When the National Football League put its ‘Rooney Rule’ in place in 2002 (penalizing teams for not interviewing minority candidates), it increased the number of African American coaches from six to 22 per cent in just four years. Note that teams were not required to hire minorities — just to consider them, and this was enough to improve outcomes. Embracing this principle might mean actively inviting or seeking out candidates, because evidence suggests that women do not even apply for certain opportunities due to their anticipation of bias. 4. TRAIN ANYONE IN AN EVALUATIVE POSITION TO UNDERSTAND IMPLICIT BIAS. If men and women alike accept that we are implicitly
5.
ADJUST FOR BIAS IN RECOMMENDATIONS AND ELSEWHERE. To compensate for implicit bias elsewhere in the system, Good Capital — an investor in social entrepreneurs — gives female-led startups extra points in the evaluation process. In their view, this simply gets these ventures back onto a level playing field. Venture capitalists might do well to follow suit.
6. EXAMINE SYSTEMS AND PROCEDURES FOR UNINTENDED BIAS. Even workplace systems that appear to be gender neutral—such as a strict seniority promotion criterion—can reinforce the status quo of male privilege. Similarly, employee referrals are one of the most effective ways to recruit, because the candidates have already been screened for appropriateness by a trusted employee. However, the risk is that a company will continue to hire more people just like its existing employee base, rather than promoting diversity. 7. CREATE MORE TRANSPARENCY AND MONITORING. The good news is, when criteria are clear and evaluation processes systematic, bias can be reduced. Such approaches limit the discre-
Further Reading: The Meritocracy Research To Date On Gender Lens Investing: Kaplan, S., VanderBrug, J. (2014):
The Rise of Gender Capitalism; Stanford Social Innovation Review, Fall 2014, 36-41; Rotman Management, Winter 2015, 40-44. On Gender as a Frame: Ridgeway, C. L. (2009): Framed Before
We Know It: How Gender Shapes Social Relations; Gender & Society, 23(2), 145-160. On Views of Meritocracy: Ladd, E. C., & Bowman, K. H. (1998): Attitudes toward economic inequality. Washington, D.C.: AEI Press publisher for the American Enterprise Institute; And, from a practitioner perspective: Zehner, J. “The Road Not Taken: What if I Had Never Left Goldman Sachs?” [linkedin.com/pulse/article/roadtaken-what-i-never-left-jacki-zehner.] Zehner also takes up this issue in “The Myth of Meritocracy,” The Conference Board Review, Spring 2010, p. 48. On Bias in Recruiting Processes: Steinpreis, R. E., Anders, K.
A., & Ritzke, D. (1999): The Impact of Gender on the Review of the Curricula Vitae of Job Applicants and Tenure Candidates: A National Empirical Study; Sex Roles, 41(7-8), 509-528. Bertrand, M., & Mullainathan, S. (2004): Are Emily and Greg More Employable Than Lakisha and Jamal? A Field Experiment on Labour Market Discrimination; American Economic Review, 94(4), 991-1013. [Rot-
man Assistant Professor of Strategic Management] Tilcsik, A. (2011): Pride and Prejudice: Employment Discrimination Against Openly Gay Men in the United States; American Journal of Sociology. 117(2) 586-626. Trix, F., & Psenka, C. (2003): Exploring the Colour of Glass: Letters of Recommendation for Female and Male Medical Faculty; Discourse & Society, 14(2), 191-220. FernandezMateo, I., and Z. King. (2011): Anticipatory Sorting and Gender Segregation in Temporary Employment; Management Science, 57: 989-1008. Fernandez, R.M., M.L. Mors. (2008): Competing for Jobs: Labour Queues and Gender Sorting in the Hiring Process; Social Science Research 37(4) 1061-1080. Barbulescu, R., M. Bidwell. (2013): Do Women Choose Different Jobs from Men? Mechanisms of Application Segregation in the Market for Managerial Workers; Organization Science. 24(3) 737-756. On Bias in Promotions and Pay: Castilla, E. J. (2008): Gender, Race and Meritocracy in Organizational Careers; American Journal of Sociology, 113(6), 1479-1526. Castilla, E. J., & Benard, S. (2010): The Paradox of Meritocracy in Organizations; Administrative Science Quarterly, 55(4), 543-576. Also, meta-analysis across a large number of studies finds that gender differences in rewards are 14 times larger than gender differences in evaluation, and that performance evaluations alone do not account for the large differences in salary increases, bonuses or promotions. Joshi, A.,
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tion of decision makers to choose based on personal beliefs or preferences, which can decrease inequality. Of course, such transparency can be a tough pill to swallow: in an effort to make progress on gender equality, Google recently released data revealing just how far it has to go. While this brought the company lots of negative press, at the same time, it puts greater pressure on them to make progress. 8. HOLD PEOPLE ACCOUNTABLE FOR RESULTS. Evidence suggests that training and awareness are not enough to make change. Inequality only declines when these programs are accompanied by incentive systems that demand accountability. As the Google example shows, transparency and accountability are tightly linked. The bottom line is that gender is a highly salient primary frame, and each of us needs to be more aware of its effects and adjust our decision-making procedures accordingly.
You may also have noticed that the term ‘affirmative action’ does not appear in this article. Regrettably, this term has come to signify that ‘underrepresented groups should receive preferential treatment’. To be clear, this is not what I am advocating: my recommendations collectively serve to get all job candidates, employees and entrepreneurs onto a level playing field when it comes to hiring, promotions and investment decisions—taking into account the privilege from which many benefit and the implicit biases that we all possess. Rather than being related to affirmative action, they are more about ‘acting affirmatively’ to create actual equal opportunity. If we want to make meritocracy real, we first need to recognize how the implicit biases in our frames of reference and in our procedures unfairly devalue women’s contributions and reinforce the privileges of dominant groups. It is my hope that leaders will embrace these first steps to moving from meritocratic myth to meritocratic reality.
In closing
You may have noticed that the recommendations outlined herein do not contain any advice to individual women to change. It has become popular to acknowledge that ‘the system is broken’ and to tell women to fix it themselves: just negotiate better, be more confident, dress for success, etc. The call put forth herein is to recognize that if the system is broken—and clearly it is—we need to fix the system.
Son, J., Roh, H.: “Constraints on Equity: A Meta-Analytic Test of the Contingent Effects of Gender on Performance and Rewards in Organizations.” Forthcoming, Academy of Management Journal.
Sarah Kaplan is an Associate Professor of Strategic Management at the Rotman School of Management and co-author of Creative Destruction: Why Companies That Are Built to Last Underperform the Market — And How to Transform Them (Crown Business, 2001). Follow her on Twitter @sarah_kaplan. Rotman faculty research is ranked in the top five worldwide by the Financial Times.
vs whites: Dovidio & Gaertner (2000): Psychological Science, 11, 315-319 Some Solutions to Bias in Recruiting: Collins, Brian W. (2007):
On Bias in Startup Investing: Brooks, A. W., Huang, L., Kearney, S.
W., & Murray, F. E. (2014): Investors Prefer Entrepreneurial Ventures Pitched by Attractive Men. Proceedings of the National Academy of Sciences of the United States of America, 111(12), 4427-4431. On Race and Privilege: DiTomaso, N. (2013): The American Nondilemma: Racial Inequality Without Racism. New York: Russell Sage, p. 3. On the Double Standard for Women: Bowles, H. R., & Babcock, L. (2013): How Can Women Escape the Compensation Negotiation Dilemma? Relational Accounts Are One Answer. Psychology of Women Quarterly, 37(1), 80-96; Eagly, A. H., & Karau, S. J. (2002): Role congruity theory of prejudice toward female leaders. Psychological Review, 109(3), 573-598; Fiske, S. T., Cuddy, A. J. C., & Glick, P. (2007): Universal dimensions of social cognition: warmth and competence. Trends in Cognitive Sciences, 11(2), 77-83; Heilman, M. E., Wallen, A. S., Fuchs, D., & Tamkins, M. M. (2004): Penalties for success: Reactions to women who succeed at male gender-typed tasks. Journal of Applied Psychology, 89(3), 416-427. A related study on minorities
“Tackling Unconscious Bias in Hiring Practices: The Plight of the Rooney Rule”. New York University Law Review 82 (3): 870–912. Goldin, C., & Rouse, C. (2000): Orchestrating impartiality: The impact of “blind” auditions on female musicians. American Economic Review, 90(4), 715-741. Some Solutions for Diversity in General: Bielby, W. T. (2008): Promoting Racial Diversity at Work: Challenges and Solutions. In A. P. Brief (Ed.), Diversity at Work. New York: Cambridge University Press.; Kalev, A., Dobbin, F., & Kelly, E. (2006): Best Practices or Best Guesses? Assessing the Efficacy of Corporate Affirmative Action and Diversity Policies. American Sociological Review, 71(4), 589-617.; Lerner, J. S., & Tetlock, P. E. (1999): Accounting for the Effects of Accountability. Psychological Bulletin, 125(2), 255-275. Elvira, M. M., & Graham, M. E. (2002): Not just a Formality: Pay System Formalization and Sex-Related Earnings Effects. Organization Science, 13(6), 601-617. Reskin, B. F., & McBrier, D. B. (2000): Why Not Ascription? Organizations’ Employment of Male and Female Managers. American Sociological Review, 65(2), 210-233.
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QUESTIONS FOR
Dr. Adrienne Boissy, Chief Experience Officer, Cleveland Clinic
Q &A A patient experience expert talks about the power of modeling desired behaviour.
Interview by Karen Christensen
How do you define the ‘Cleveland Clinic experience’?
Our guiding principle is, Patients First, and achieving that takes more than world-class clinical care: it requires care that addresses every aspect of a patient’s encounter with the Clinic — from their physical comfort to their educational, emotional and spiritual needs. We were the first major academic medical centre to make patient experience a strategic goal, the first to appoint a Chief Experience Officer, and one of the first to establish an Office of Patient Experience — which I oversee. Our mission is to ensure consistent, relationship-centred care by partnering with caregivers throughout the Clinic to exceed patient (and family) expectations. Our team of professionals serves as an advisory resource across the Clinic; provides data analytics; identifies and supports sustainable best practices; and collaborates with a variety of departments to ensure the consistent delivery of relationship-centered care. Ironically, just a few years ago, the Clinic’s patient-experience scores were not very good. Tell us about the quest to change that.
It’s true: we had very low scores a few years ago. But then our CEO, Dr. Toby Cosgrove, had two transformative experiences. Dr. Cosgrove is a cardiac surgeon who had mastered the clinical realm of doctoring: he had multiple patents, was internationally renowned, and was running the rotmanmagazine.ca / 8
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Not everybody knows how to be empathic; for some, it comes much more naturally than for others.
Cleveland Clinic. Shortly after taking on the CEO role, he was at Harvard Business School giving a talk about our approach. When he finished his talk, a young woman raised her hand and said, ‘That’s all great Dr. Cosgrove; but a while back, I was thinking about where to take my father for heart surgery, and I ultimately decided to take him somewhere else — because I heard that you don’t teach empathy at the Cleveland Clinic. Dr. Cosgrove, do you teach empathy?’ Toby was floored. He had just told some amazing stories about our innovative work, but what really mattered to someone in the audience was this concept of empathy. Not only did it matter, but it had influenced where she decided to take her loved one. Shortly thereafter, Toby was in the Middle East, attending the dedication of a hospital, when the hospital’s mission was described as ‘serving the body, the spirit, the heart and the soul of our patients’. When he looked out into the audience, he saw people crying, and he was struck by how moved they were by the concept of holistic care. When he returned to the Clinic, he appointed our first-ever Chief Experience Officer and made ‘Patients First’ our strategic priority. One major step on our journey involved putting 44,000 caregivers through the Cleveland Clinic Experience — a halfday program where people are placed in multidisciplinary groups. For instance, one group might include a neurosurgeon, a nurse and a housekeeper. They all sit down with a facilitator and talk about why our work is so important, sharing some of their own stories. They also talk about the Clinic’s values, and how to put Patients First into action. After each session, everyone made a commitment to the principle that, ‘We are all caregivers’ — and that was a very important cultural shift for us. The next step was to instill some skills around service, with the idea that everybody who works here — at any time — should be able to step in and offer service recovery to every patient they encounter. Your clinic embraces a group-practice approach, which has been shown to enhance collaboration and innovation. Describe how it works.
Cleveland Clinic is a non-profit group practice with physi-
cian leadership — the second-largest group practice in the world. Our model is fairly unique in that all physicians are on salary. There are no bonuses or financial incentives. All physicians are subject to annual performance reviews and are on one-year contracts. Our delivery system model is also distinctive. In 2008, we transitioned from the typical profession-oriented organization, designed around physician competencies — such as surgery — to a patient-oriented approach that consists of multiple institutes. An example is our Heart and Vascular Institute, which is comprised of cardiologists, cardiothoracic surgeons, and vascular surgeons in the same location to handle whatever cardiovascular issue a patient may have. In all, we have 28 such institutes, ranging from Anesthesiology & Pain Management to Wellness, in which caregivers can come together and discuss innovative approaches. In short, our institute structure puts patient needs first — ahead of medical practice traditions. It also promotes innovation and the efficient use of resources, fostering teamwork to solve complicated problems. You mentioned that employees at the Clinic — even your CEO — are on one-year, renewable contracts. What does this do for your work culture?
First, it’s intended to be a benefit to our staff and caregivers. Just before the end of their yearly contract, each staff member sits down with their local leader and a Board of Governors member, and they have a meeting about their performance, how they want to progress, and what some of their challenges are. This really allows us to get a pulse on the culture that people are working in — and any major issues that we should be addressing. It also lets each employee know that we are serious about enabling their development, and that their organization is actively listening to them. The second piece is about accountability. Annual reviews are also an opportunity to make sure that we’re messaging our values sufficiently — and holding people accountable for them. As indicated, the patient experience is our focus, so that is built into every caregiver’s review process. rotmanmagazine.ca / 9
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It is no longer enough to master the clinical aspects of what you do—and for many caregivers, that is an entirely new concept.
Thirdly, perhaps more than anything, is the idea that we are deeply invested in our employees’ success, and if there are things we could be doing to make them successful, this provides an opportunity to learn about that, and then execute on it. One key way to lower costs in the healthcare system is to improve patient outcomes. What goes into your thinking around that?
As I indicated earlier, we’re coming out of a very doctorcentered era in healthcare, and we have swung into a space where lots of people are talking about a more patient-centered approach. The Holy Grail is actually what I would call a ‘relationship-centered approach.’ As caregivers, we have a chance to bring real value to the table—but so do patients. We have a shared goal, and together, we can design something better than any of us could do alone. For example, one of our regional partner hospitals tackled readmission rates and ER visits — both of which are very costly. They reached out to 20 patients who were recently admitted to a local hospital emergency room, through physician or caregiver phone calls to those patients. The calls were intended to check in these patients and make sure a) that they were doing okay and b) to attempt to prevent another ER visit. This very simple concept had a dramatic impact. We are finding that, if we can engage people in unique ways, we can achieve greater outcomes; and not just outcomes that we define — but outcomes that our patients help to define. A few years after your CEO was asked about it, how are you bringing empathy to the patient experience?
Making empathy a reality entails a few things. One is encouraging reflective competence. We’re not an organization that teaches scripted interactions. What I would much rather promote is having people look at the patient sitting in front of them and think about where that patient is, and what words they may need to use on that day to meet the patient where they are. This work is challenging, because most clinicians have been doing things in a certain
way for a long time — and they are probably pretty effective at communicating. That being said, we are lifelong learners, and we should be creating safe, fun environments where we can all learn from each other’s communication techniques. The second thing we promote is modeling. Organizations are beginning to put patient satisfaction scores in front of their physicians. It can be tempting to hammer on them about how they’re going to improve those scores, but to me, by doing that you aren’t modeling the very behaviour that you are hoping to instill in your caregivers. Another way of approaching it is to say, ‘Patient satisfaction is one way of capturing the patient experience, and it seems some patients don’t feel that you are communicating very effectively with them. Tell me what you think about that’ — as opposed to running with judgments that can feel very offensive to the clinician, who is likely trying to do their best. In short, it’s about modeling the behaviours we want others to adopt in everything we do as leaders. A third tool is transparency — being completely upfront with the data we have about patients’ perceptions. Our clinic has done that internally for about three years. Every quarter, we provide unedited patient satisfaction data and comments to our physicians. In April of last year, we also took this information public — so now anyone can search online for our physicians and get a sense of what patients are saying about them. The last piece is resources. You can’t hold people accountable for being empathic and drive transparency around that without having the required resources in place. The fact is, not everybody knows how to be empathic; for some, it comes more naturally. For example, after he went through some of our training, I had a neurosurgeon say to me, “I’ve been waiting my whole life for somebody to tell me what to say in these situations!” It struck me that you can’t just say to somebody, ‘Try to communicate more effectively’ or ‘Do better’; you have to have programs in place that are designed to meet the needs of your people. It took us a long time to develop our program, because we wanted it to be evidencebased — but we also wanted it to include some really creative rotmanmagazine.ca / 10
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ways of getting people to think about the challenges of using language that effectively conveys that they care. Your CEO once said, “Data-driven medicine is helpful as an adjunct to the doctor’s experience and intuition, but it’s not a replacement for it.” Describe how you walk the line between medicine as art and medicine as science.
The traditional, doctor-centered approach embraces the idea that Medicine is all about science, which it’s clearly not. But it’s not all art, either. It is both, and nowadays, caregivers must do both. It is no longer enough to master the clinical aspects of what you do — and for many clinicians and caregivers, that is an entirely new concept. I think the best way to balance the art and science of medicine is to have a strategy that grabs both peoples’ hearts and minds. As I’ve indicated, that includes modeling empathy, compassion and relationship-centered care. At the same time, you have to be able to deliver those lofty concepts with some very tangible tools — so that when somebody says, ‘I don’t know what to say in this particular moment’, you can brainstorm with them to come up with language that is authentic to them. We now have 30 to 40 years of literature on what the best practices are — particularly around communication and empathy. It’s not rocket science, but you do have to create a context where people are receptive to it, and we’ve invested heavily in making sure that the content we deliver speaks to the real challenges our people are facing.
meetings, at executive team meetings, in casual conversations. We regularly have patients come in and talk to our staff, so their stories are woven deeply into the fabric of how we strategize and operationalize change and innovation here. But it’s not just about setting a standard: it’s also about holding people accountable to that standard — not just in a punitive way, but in a very human way. The other day, I was off duty, sitting in a close relative’s room, in plain clothes, when a caregiver came in. She didn’t introduce herself, and she started to ask me a number of questions. I immediately said, “I would be happy to answer those questions, as soon as I know who you are and what role you are playing in my relative’s care.” At that moment, it struck me that, all-too often, we let these moments go. Without any real context, we just answer the questions. I think we have to start reflecting back the undesirable behaviour, right then and there — by saying, ‘Lets rewind. I appreciate that you may be very busy and I’d like you to take a minute to introduce yourself.’ I have come around to the idea that organizational culture is made up of a thousand different choices that are made each and every day. As a leader, if you see behaviour that doesn’t fit with the culture you aspire to, you have to call it out. Of course, you should also call it out when it does meet expectations. The question is, what choices are being made, every moment, to create the culture that you aspire to?
Peter Drucker called healthcare organizations ‘the most complex form of organization that we have ever attempted to manage’. What key lessons do you have for leaders in other industries?
My first lesson would be about modeling. I have truly come to appreciate the importance of walking the walk and talking the talk. In every single interaction that you have, you should work hard to model the behaviour that you are trying to drive. The second lesson would be around setting expectations. We talk about ‘Patients First’ all the time — in staff
Dr. Adrienne Boissy is the Chief Experience Officer at the Cleveland
Clinic, based in Cleveland, Ohio.
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Date:15-11-18
Page: 109.p1.pdf
QUESTIONS FOR
Efrat Peled, CEO, Arison Investments
Q &A
An Israeli investment company’s CEO describes the business impact of embracing humane values.
Interview by Karen Christensen
The financial sector is not renowned for creating shared value for society. Tell us how you set out to defy this expectation.
A significant portion of our companies operate in emerging markets, so we actually believe that financial services are in a great position to have a major impact on global communities. We have found that succeeding in emerging markets demands one simple thing: being focused on creating mutually beneficial, long-term business partnerships. We started out with a vision that ‘Doing Good is Good Business’, and we proceeded to slowly transform our day-to-day decision making, taking this notion into consideration at every level — from the front lines, to our operational teams, to the board level. We are upbeat about the prospects for emerging markets. The middle class in these economies is enormous, and 65 to 70 per cent of the population is under the age of 35. In emerging markets as a whole, by 2025, there will be $30 trillion of new consumption. Our observations of what works rotmanmagazine.ca / 12
PHOTO: CORBIS
Doing well by doing good: Bank Hapoalim is ranked #1 in its peer group on the Tel Aviv Stock Exchange.
are just some of the pieces to the puzzle for creating a thriving business in emerging markets, but we are convinced that a commitment to long-term, values-based strategies is a universal principle. Our focus on ‘doing good business’ has results to back it up: Bank Hapoalim’s share price appreciated +65 per cent between 2012 and 2015, with a compounded annual growth rate of 13.5 per cent. In the last five years, the Bank has been ranked #1 in its peer group among the most actively traded stocks on the Tel Aviv Stock Exchange. It’s hard to argue with results like that.
ning, and for monitoring and adjusting the initiative over time. Rather than hiring consultants, we are engaging our internal talent and encouraging learning. If you are going to do this, it is critical that your evaluation and compensation system credits people for these efforts. The fact is, every employee has interests and passions that lie outside of their daily job tasks, and if you enable people to put those interests to work, they will come up with amazing things.
You have said that basic humane values are integrated in your organizations’ daily routines. How so?
A key part of our vision is achieving ‘financial freedom’ for our customers. We believe that the bank and our customers are jointly responsible for the customer’s financial potential and growth. We started out by creating personal budget tools, and last year, we created the Israel Forum for Financial Freedom, which sees regulators from the Bank of Israel, the pension funds, and other financial institutions come together to share ideas around financial freedom. We believe collaborating with regulators and other market players will bring about the best solutions, on all levels and for all stakeholders.
When we got started, we could not copy-and-paste an existing methodology — because no other infrastructure or investment organization had developed one. So, we decided to engage the most powerful force that we had at our disposal: our employees. Once we determined the scope of what we wanted to achieve, we recognized that the ability to achieve it rested with them. One of the first things we did was create innovation forums throughout the organization, covering topics like sustainability, financial freedom and volunteering. We asked each of our divisions to select the employee who cared most about each issue, to head up each forum. Today, we have close to 100 people engaged from all of our subsidiaries, and they are responsible for finding innovative ideas and implementing them. Let’s say an employee from Bank Hapoalim is a member of the sustainability forum, and the group decides to initiate a specific activity. That person is responsible for incorporating the idea into the bank’s strategic annual plan-
Describe how you go about embracing a broad value like ‘Freedom’.
Talk a bit about your work in Africa, and the challenges and opportunities there.
Our company first began working on infrastructure in Africa 60 years ago, so this is not new for us. The scope of opportunity in Africa is simply amazing; but for now, ‘sustainability’ means very different things there than in some other places. When we work on a project in Israel or Germany, sustainability is around green building and energy use; but in Africa, we often focus more on education or simple hand rotmanmagazine.ca / 13
Three Keys to Success in Emerging Markets 1. Align the Approach. Very early on, we evaluate the business opportunity while also assessing the host government’s approach to its broader national development agenda. Do our values and strategies align with decision-makers’ institutional goals? Does our presence help to achieve other outcomes that are important to the country – like training people with new technical expertise or creating a new industry? Can we find shared outcomes that ensure we will be working together for the long run? If a business doesn’t engage a government in this dialogue before entering a market, the potential value of the partnership quickly diminishes. In the Philippines, for example, government spending increased 17 per cent in a year, with major investments in innovation and efficiency, the two pillars of our water efficiency business, Miya. Partnering with Maynilad, the local private water utility in Manila, we designed and implemented a comprehensive solution using new technology to solve an old infrastructure problem. We combined special software with human ingenuity to identify, monitor, and repair leaks in old pipes. As a result, about 768 million litres of water per day are saved, and today an additional 2.6 million people now receive a consistent flow of fresh water from the municipal system. 2. Think in Partnership Terms. When we make the decision to enter a market, we embrace the notion that the relationship should be mutually beneficial, and take responsibility by shifting our mindset from ‘total resource ownership’ to ‘filling institutional and knowledge voids’. Shikun & Binui,
hygiene for children. This is what sustainability means in those places, so we engage governments and local people, and we work with them to create a plan that suits their capacity. It’s not about us, it’s about what fits their needs. Many organizations embrace diversity of gender, culture and race in their hiring practices, but you believe the most enlightened employers also seek a less talkedabout form of diversity. Please describe it.
In my view, diversity of thought is just as important as all of those other types of diversity. In every important project that we undertake, we make a point to have people from many backgrounds and specializations involved — and we make sure that they all get a chance to contribute. The fact is, decision-making processes move very fast these days, requiring leaders to run flexible capital struc-
our global infrastructure, real estate and renewable energy company, sells the waste by-product of an infrastructure project to local concrete plants for energy production. About 70 per cent of our material purchasing in four markets – Guatemala, Kenya, Tanzania and Uganda – is handled locally, putting more than $2 million annually into those local economies. We also have sustainability managers who monitor it, so that our core business promotes local business. It’s a twoway street for us, and I hope, for many of my corporate peers: while an emerging market entry signifies what the country offers us, we are committed to playing our role in supporting the local economy and advancing it. 3. Ensure Skills Transfer Through People. One of the best ways to make partnerships last is through knowledge transfer and skill-building of local teams. In our projects, we emphasize a true mixing of foreign and local talent. In the Philippines, 450 local engineers have been trained with Miya throughout this process, ensuring advances are sustainable for the long-term. Shikun & Binui is also dedicated to investing in and training talent, employing 11,000 locals in a range of projects worldwide. Once projects are completed, Shikun & Binui integrates staff into the company’s local activities and operates sustainability workshops for senior and midtier management. Ultimately, real and lasting impact occurs through the interactions between people on a sustained basis. This also helps to cement advanced standards, supply chain practices and sustainable management. - Efrat Peled
tures and cash flows, while seeking tactical opportunities that are in line with long-term strategies. Any business that wants to succeed on a global level must embrace diverse thinking, and their model must incorporate technological solutions and developments, together with a genuinely humane, moral and values-based approach.
Efrat Peled is Chair and CEO of Arison Investments, which manages
a $2.5 billion portfolio in finance, real estate, infrastructure, renewable energy and water efficiency, with 27,000 employees in more than 40 countries across five continents. A qualified CPA, she holds an MBA from Kellogg-Recanati and is a former member of the World Economic Forum’s select group of Young Global Leaders and the Clinton Global Initiative Lead group. She has been repeatedly ranked on Fortune’s 50 Most Powerful Women in Business. rotmanmagazine.ca / 14
Questions for: Gretchen Rubin
Q &A The New York Times best-selling author of The Happiness Project explains how we can influence our own happiness.
Interview by Carolyn Drebin
On paper, you appear to have it all: health, family, career; what made you decide to embark on a ‘happiness project’?
I do have a lot to be happy about, but one day I realized that I wasn’t as happy as I should be. I found myself getting annoyed by lots of little things, and I was complaining a lot more than I should. I wanted to be more grateful and appreciative for the everyday, and to set higher standards for myself. Research shows that so many positive outcomes emerge from happiness: happy people are more productive, more altruistic, more creative, more likeable and physically healthier. So I decided to dedicate an entire year to trying to be a happier person. How do you define happiness?
People have been contemplating this for thousands of years. Aristotle even called happiness ‘the chief good’ in life. But the fact is, it has a different meaning for each and every one of us. Research shows that genetics accounts for about 50 per cent of our happiness; life circumstances — such as rotmanmagazine.ca / 15
Accepting your strengths and weaknesses means facing up to the fact that certain things may never happen for you.
age, gender, ethnicity, marital status, income, health, occupation and religious affiliation account for another 10 to 20 per cent; and the rest is a result of how we think and act. So clearly, we have the ability to influence our own happiness; the question for me was, how? I read widely on the topic — everyone from Benjamin Franklin to Virginia Woolf to the Dalai Lama has something to say about happiness, and many common themes emerged: the importance of relationships, self-knowledge and atmospheres of growth, to name a few. The vocabulary was always different, but the key ideas were the same. I found Franklin particularly inspiring: he came up with a Virtues Chart, featuring 13 virtues that he wanted to cultivate: temperance, silence, order, resolution, frugality, industry, sincerity, justice, moderation, cleanliness, tranquility, chastity and humility. He made a chart with these along the top and the days of the week underneath, and each day, he would score himself on whether or not he had practiced each virtue. It turns out, he was on to something: research shows that we are much more likely to make progress on our goals if they are broken into concrete, measurable actions, with some kind of structured accountability and positive reinforcement. I decided to create my own version of Franklin’s model, melding his approach with the findings on what makes us happy and the importance of structuring our goals. I created a personal calendar for the next 12 months and gave myself a different subject to focus on each month. The final month, December, was cumulative, dedicated to putting it all into practice. Here’s what my calendar looked like: January: Vitality February: Marriage March: Work April: Parenthood May: Leisure June: Friendship July: Money August: Eternity September: Passion October: Mindfulness November: Attitude December: All of the above
What did your resolutions look like?
Once I chose my areas of focus, I came up with a few ‘resolutions’ for each month. For example, in January my focus was Vitality, so my resolutions included things like going to sleep earlier, exercising more, tossing things out and organizing my home, and tackling a nagging task. And for my marriagefocused month, I vowed to quit nagging my husband, to ‘fight right’ and to give him more proof of my love. December must have been an interesting month, as you sought to cover off all 11 areas at once. How did that go?
It took a huge amount of discipline and self-control — not to mention time. For the entire month, I organized things, I sang in the morning, I acknowledged people’s feelings, I left things unsaid, I asked for help, I didn’t eat any fake food. Of course, I also failed to do all these things, but I was astonished at how effectively they worked to make me happy whenever I did faithfully do them. Did I have one single perfect day? No, but I kept trying. Tell us about your 12 Commandments.
These are my core beliefs. As I worked on identifying my resolutions for each month, principles began to emerge. I boiled down my values and tried to condense each larger idea into a few words. For example, ‘no calculations’ means, ‘stop weighing and measuring everything, and just be in the moment’. Your number one commandment is: Be Gretchen. How did this unfold over the year?
Accepting your strengths and weaknesses means facing up to the fact that certain things may never happen for you. By the end of the year I was definitely a ‘truer’ version of myself. I had to let go of many things, sometimes sadly. The world offers us so much, but it’s important to recognize and accept our limitations. Letting go of all the things that I am not was a big part of this. Talk a bit about your eight ‘Splendid Truths’.
Studying happiness, specific fundamental principles emerged. Throughout Buddhism there are numbered lists, so I made up my own and dubbed them the Eight Splendid Truths. Everyone who starts their own Happiness Project rotmanmagazine.ca / 16
EIGHT SPLENDID TRUTHS Everyone who starts their own Happiness Project will come up with their own list, but this is mine. 1. To be happier, you have to think about feeling good, feeling bad and feeling right in an atmosphere of growth.
4. You’re not happy unless you think you’re happy.
will come up with their own list, but this is mine. The one that seems to resonate the most with people is, “The days are long, but the years are short”. I used it in the context of parenthood, but it’s applicable to life in general. This is one of life’s fascinating paradoxes. Time passes, and we have to focus on what matters most. I try to remember this, and live in the moment and find happiness here and now.
5. I can build a happy life only on the foundation of my own nature.
In an age of social media, is it inevitable that we compare our happiness to everyone else’s?
2. To make yourself happy is to make other people happy; To make other people happy is to be happy yourself. 3. The days are long, but the years are short.
6. The only person I can change is myself. 7. I can’t make someone be happy and no one else can make me happy. 8. Now is Now.
THE SECRETS OF ADULTHOOD People don’t notice your mistakes as much as you think. It’s okay to ask for help. Do good, feel good. It’s important to be nice to everyone. By doing a little bit each day, you can get a lot accomplished. You can choose what you do, but you can’t choose what you like to do. What you do every day matters more than what you do once in a while. If you’re not failing, you’re not trying hard enough.
For me, social media such as Facebook is an intensifier of human nature. As a tool to stay in touch with people, it can absolutely be an aid to happiness. Ancient wisdom, popular culture and modern science all agree that strong social connections and solidifying our bonds with other people boost our happiness. It’s when people become too overwhelmed, or start comparing their happiness to everyone else’s, that it becomes a ‘good servant/bad master’ kind of situation. In that case, we need to stop and figure out if the digital tool is adding to, or taking away from, our happiness. Is there such a thing as complete happiness?
True happiness as an ideal is a distraction, because we can never arrive at a final ‘end’. It’s really more of a process and a journey than a destination. Joy, contentment and fulfillment are all ways of experiencing happiness, and focusing on these things is much more productive than having one ultimate goal. At the end of my experiment, my husband told me he felt that this project was really about me trying to get more control over my life. He had a point; the feeling of control is an essential element of happiness — and has been proven to be a better predictor of it than, say, income. Having a feeling of autonomy, of being able to choose what happens in your life and how you spend your time, is crucial. I definitely learned how to take control of my own happiness.
Gretchen Rubin is a Yale Law graduate and the author of the New York Times #1 best-seller The Happiness Project (Harper, 2011) and most recently, Happier at Home (Harper 2013). She has addressed corporate audiences at GE, Google, LinkedIn and Procter & Gamble. rotmanmagazine.ca / 17
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