Building Health Services in a Rapidly Changing Landscape: Lessons in Adaptive Leadership and Pivots in a COVID-19 Remote Monitoring Program.

Adaptive leadership has become an essential skill for leaders in health systems to respond to the COVID-19 pandemic as new knowledge emerges and case counts rise, fall, and rise again. This leadership approach has been described as an iterative process of taking a wide view of the situation, interpreting the meaning of incoming data from multiple directions, and taking real-time action. This process is also common in start-ups, which attempt to create new products or services of uncertain value for consumer markets that may not yet exist. Start-ups manage uncertainty through "pivots," which can include changes in the target group, need, features, or intended benefit of a product or service. Pivots are large changes that account for the high likelihood of getting something wrong during development, and they are distinct from the "tweaks" or small tests of change that define quality improvement methodology. This case study describes three pivots in the launch of a remote monitoring program for COVID-19. Adaptive leadership helped inform strategic decisions, with pivots providing a framework for internal and external stakeholders to articulate options for changes to address shifting needs. There is considerable uncertainty in the appropriate design and implementation of health services, and although this case example focuses on the use of adaptive leadership and pivots during a pandemic, these strategies are relevant for health care leaders at any time.