It is the most common question I am asked these days in leadership development sessions: How do I get buy-in? It is not surprising given the nature of the challenge that health care leaders face. We are confronted with the need to bring almost tectonic changes to an enormous $2.6 trillion industry that for the past half century has been left to chart its own independent way. The challenges include bringing new models of care delivery online, using comprehensive new technology to manage information, joining with new partners to integrate care along a continuum, responding to the consumer needs of patients and always delivering better service while reducing costs.

Every one of these changes is an important part of health care change and reform. And every one of them asks the health care worker, clinician and non-clinician alike, to buy-in to the new way of doing health care business. This resistance to change and the reluctance to buy-in is easy to understand. We have by and large left a great deal of independence in the system, rewarding providers of all varieties to remain outside of the usual patterns of accountability. Now in a dizzyingly quick fashion the calls for reform make demands that have never been proffered before.

Leaders have three ways to bring their followers along: authority, reward and experience. All are legitimate and vary as to their fit to the demands of particular situations.

Authority has many dimensions and may be the most common way that leaders seek buy-in. The most common use of authority is the command to buy-in from an individual who controls a position of authority. This use of structural power alone rarely has the capacity to engage those that we want to participate in a change in a meaningful way. The impact of authority to gain buy-in is enhanced if the leader has taken the time to develop the commitment to a common understanding of the challenge. This common ground looks backwards to the shared values and aspirations of the organization and forward to achieving these goals in a world that is rapidly changing. The leader’s advocacy for such common ground is a vital contribution, one that is often overlooked. The expectation of many leaders is that such buy-in already exists throughout the organization and that all that is required of them is to provide the direction for the future. But the task of leadership should be more focused on simpler more direct issues as: “This is what we do together.” “This is how our work and values will be challenged in the coming years.” And perhaps most importantly, “This is what we try to achieve, but we must do this in a new way given the changing demands of our world.” Raising issues and questions such as these and providing time and resources to come to understanding enhances the power of authority and recognizes that buy-in is a process, not a dictate.

Many leaders achieve buy-in by providing rewards. In this form of persuasion the reluctant participant perceives some loss at the prospect of moving forward with a change; and the leader compensates for the loss with a reward or encouragement. When the leader uses rewards to purchase buy-in, it is essential to remember that there is a great range of what individuals and groups will desire for compensation and also that the currency available to the leader is richly varied, and oftentimes the more powerful rewards are the non-monetary variety. Recognition, opportunity, challenge, pride, and support are important to most of our colleagues. Buy-in can be advanced by framing the challenge in a way that does not command participation of others, but leads them to engage because they value other qualities that surround the challenge of the change.

Finally, experience can lead to buy-in. If we are leading a change effort, then we have gone through a process in which we struggled with all of the dimensions of the challenge and the proposed change and have come to terms with the solution. We now want to share this conclusion with others so that they can move to a shared position, but in a more efficient manner. So we use authority to propose the change or offer a reward for change as compensation. We do this in what we think of as everyone’s best interest, but we create mischief when we do. The experience of actually struggling with the challenge, exploring the options, being creative in order to see new solutions is essential to buy-in in many instances. It is always slower or less efficient then commanding change or paying off a reluctant participant. Ultimately though it achieves a level of commitment and understanding that is essential if the leader is to have the full engagement of those that must move ahead with the change.

Every leader who tries to get the elusive buy-in to a change will work with all three of these elements: authority, reward and experience. These will be combined in novel ways for individuals and groups; and they will change as circumstances and understanding are altered in the process of change. Being experimental about this process is unnerving in unfolding situations, but there is really no alternative to leading change effectively.