The Knowns and Unknowns of Health Care Meta-Leadership

Questions in Health Care
The number of unknowns in the health care world are endless, making it crucial for health care leaders to use a wide “meta-“ view of challenges and solutions to ensure success.

The state of health care in this country could best be described as predictably unpredictable. The future of the Affordable Care Act—and the financing that underlies it—is open for question. Evolving technology challenges health care organizations both to keep up and to stay smart in how they adapt to new opportunities and capabilities. And the face of health care organization is changing as systems face mergers, closures, and non-traditional players entering the fray. The competitive landscape is turbulent.

Nevertheless, each day health care leaders make decisions, develop long-range plans, and remain adaptive to the environment that surrounds them. Those decisions are accomplished even when all the facts are not known: Decide before you know? The conundrum is both counter-intuitive and inescapable.

As one of those leaders, you face a combination of knowns and unknowns. Clarity on the knowns is relatively easy. It is the search for and reliance upon data, evidence, and scientific analysis. It is noteworthy that just a few years ago, the notion of “evidence-based medicine” assumed the clarion call of a movement. Going with the gut, relying upon intuition, and building off experience were simply not adequate. These practices created the illusion of knowing when in fact, the facts weren’t there.

Nevertheless, the unknowns persist and they can be dangerous. What if that decision could have been improved by accessible information that you overlooked or simply ignored? What if you make assumptions based on data that was, in reality, guesswork? If others know what you don’t, you are at a competitive disadvantage.

Making yourself deliberately aware of the unknowns is a critical and complex leadership responsibility.

As a health care leader, you face this ambiguity every day. When you make decisions, you acknowledge that you are doing so with limited information. What do you really know and what are the very real unknowns? Making yourself deliberately aware of the unknowns is a critical and complex leadership responsibility. In meta-leadership terms, we call this intentional process, “Driving to the knowns.”

The challenge for you is to distinguish between what is known from what can be known. The former includes information that is available for you to retrieve and apply. The latter includes information and questions that could be asked and answered, though only if you are insightful about both their importance and accessibility. Without making these distinctions, you run the risk of both assuming you know something when you don’t AND neglecting to gain access to information that could be available, though only if you go for it.

Unknowns fall into three different categories:

  1. For some of those unknowns, you are aware that you are unaware. These are the known unknowns. You know what you don’t know. Your awareness prompts your hunt for the information that could turn those unknowns into knowns. You are careful when you embed assumptions or reach decisions in this recognized unknown zone. Actively seek and then assemble answers to assist your deliberations and decisions. Placing that information then into the known knowns builds a firmer foundation upon which to plan and lead. Many leaders either ignore or dismiss that information, creating a perilous leadership trap when it later comes out that the information was available and discounted.
  2. More complex unknowns may escape your awareness, a problem because these unknown knowns are available to others and not to you. This information is for you a mysterious abstraction since it is outside the bounds of your day-to-day thinking. For example, your two primary competitors plot a merger that would overrun your service area and radically decrease your relative market share, volume, and therefore, revenue. This is bad news. Are you prepared to adapt? Or, Congress suddenly passes legislation that funds and expands services you provide. This is good news. Are you ready to expand scope and scale to meet the opportunity? Or, your boss has turned sour on your performance without giving you any notice of the problems. This is terrible news. Are you ready to respond, change, or move on? This category of unknowns requires you to imagine beyond the obvious, to consider a wide range of possibilities, and to ponder how you might take action. It is an exercise of continual curiosity. Even acknowledging the possibilities is a step in the right direction, keeping you on your toes about what could lurk around the next corner.
  3. Finally, the most complex and foreboding category are the unknown unknowns. This is information known to no one. It could encompass future events that are hard to predict or account for, such as a crisis or breakthrough change. For example, an active shooter in your work place could spark panic and chaos that is difficult to predict. The unknown unknown could be a surprise convergence of events: the election of an unlikely political candidate, a new treatment that reshapes expectations of care, or a banking collapse that threatens the financial health of your organization.Life itself is replete with unknown unknowns: we don’t know how long we’ll live, the health we will enjoy or lose, and what will happen to loved ones. These unknown unknowns are a fact of life just as they are a mystery of leadership. Though the information is hidden, you seek to learn what you can, filling in pieces of information like a detective, putting clues together and providing images of what might lie ahead and what you, as a leader, can do about it.

The challenge is to distinguish between what is known from what can be known.

Leading in a health system is to continually and deliberately balance and assess these knowns and unknowns. Employing a wide “meta-” view of problems and possible solutions – along with the systematic framework for driving to the knowns – creates clarity of thinking and action. By carefully observing and assessing patterns and trends, and by intentionally making yourself aware of what is known and unknown, you are more likely to reach your best possible decisions and outcomes.

This is Meta-Leadership thinking and practice, designed to systematically reveal and apply the knowns to your health care decision-making and actions.


Harvard T.H. Chan School of Public Health offers Leading in Health Systems: Integrating Effort, Improving Outcomes, a high-impact health care leadership development program, which focuses on meta-leadership.