Attitude > Talent

 I was stunned to read last night that the incredibly talented actor, Chadwick Boseman who starred in the movies, 42, Get on Up, Marshall, Draft Day, Da 5 Bloods, and Black Panther died yesterday of colon cancer at the age of 43 years.  I recently posted about the character he played in the movie, "Draft Day" (Vontae Mack).  His fight with colon cancer was not well publicized - in fact, he played a number of his roles while receiving treatment for his cancer.  It was very sad news for all of us to hear.  I realize that many, if not all, of his other roles (Jackie Robinson, James Brown, Thurgood Marshall, and the King of Wakanda) had greater impact than his portrayal of "Vontae Mack", but I will choose to honor him today with another lesson on leadership from his movie, Draft Day.

The whole premise of the movie centers on one of the main characters, Sonny Weaver (played by Kevin Costner), the General Manager of the Cleveland Browns.  Weaver suddenly finds himself at the center of the sports world when he trades for the first pick in the NFL Draft.  The Browns are in desperate need of talent (art imitates life, right?), and everyone thinks Weaver should select the Heisman Tropy-winning quarterback, Bo Callahan, with the first overall pick.  The problem is that Weaver's gut instincts are telling him to pick the All American linebacker, Vontae Mack instead.

As the movie progresses, we learn that Bo Callahan has several red flags.  First, he doesn't seem to have any friends.  Weaver learns, for example, that Callahan had thrown a huge bash at a local bar on his 21st birthday, and not one of his teammates attended.  As his college football coach suggested, this is certainly not a crime, nor is it reason alone not to draft him.  However, while watching game film, Weaver notes that Callahan never celebrates with his teammates after a touchdown or win.  Finally, Callahan failed the $100 test.  One of the football teams sends a playbook to players that they are interested in drafting, and there is a $100 bill taped to one of the pages towards the end of the playbook.  Test #1 is whether the players actually read enough of the playbook to find the $100 bill.  Test #2 is whether they come clean and admit that they had found it.  Callahan fails both tests.

In contrast, Vontae Mack seems to have just as much talent as Callahn (albeit on the opposite side of the ball), but is the quintessential team player.  His level of dedication, passion, and commitment to his team is well-known throughout college football.  He even adopts his two nephews (during college), after his older sister dies from cancer.  Whereas Bo Callahan has all the talent in the world, he is not a team player, nor is he very dedicated to playing football.  Vontae Mack, on the other hand, has all the intangibles as well as the talent.

So if you were Sonny Weaver, which player would you rather have on your team?  Perhaps the answer can be found in a recent video from the motivational speaker and author, Simon Sinek (see also my previous post on this issue, "Do the Cleveland Browns Have a Trust Issue?").  In this latest video, Sinek talks about the U.S. Navy SEALs - specifically, SEAL Team Six, the elite of the elite.  Sinek asked the Navy what kind of SEALs they were looking for when selecting for SEAL Team Six.  They responded with a 2x2 graph - "trust" on the x-axis and "performance" on the y-axis.  "Trust" equated with emotional intelligence, attitude, dedication, and commitment to the team.  "Performance" was exactly what you would think - skills, knowledge, and expertise.  The Navy avoids individuals who are in the lower left quadrant (low trust and low performance) - because who would want the individuals who don't perform very well and no one trusts?  Of course they wanted individuals in the upper right quadrant (high trust and high performance) - that makes perfect sense too.  But when Sinek asked the Navy who they preferred between the low trust / high performance and high trust / low performance category, the Navy said trust beats out performance every time.  

Vontae Mack was a high trust / high performance individual at his best and probably a high trust / moderate-to-high performance even at his worst.  Bo Callahan?  Low trust / high performance for sure.  The choice for Sonny Weaver wasn't that hard after all.  "Vontae Mack, no matter what."  How many times do we see that in our industry?  Do hospital leaders build their teams around Vontae Macks or Bo  Callahan's?  

By all counts, Chadwick Boseman seemed like a high trust / high performance kind of individual.  May he rest in peace.

A few of history's greatest leaders...part II

We should all have role models, mentors, confidants, and trusted advisors to help us along our way in life.  I have been fortunate to have several throughout my career.  There are countless leaders throughout history from whom we can learn how to deal with adversity, how to create a vision and execute a plan to attain it, and how to develop talent.  Here are a few additional individuals who I have found inspiration from how they approached leadership.

1. Rosa Parks:

"I have learned over the years that when one's mind is made up, this diminishes fear; knowing what must be done does away with fear."

Rosa Parks was an American civil rights leader who is perhaps best known for her pivotal role in the Montgomery bus boycott of 1955.  She has been called the "mother of the freedom movement" as well as the "first lady of civil rights."  Her refusal to give up her seat is the very essence of leadership - taking a stand (in her case, by not standing up) in order to do what was right and just.  

2. George Washington Carver:

"When you do the common things in life in an uncommon way, you will command the attention of the world."

When I was young, I was obsessed with George Washington Carver!  There was a series of children's books that focused on the childhood of some of America's greatest leaders, scientists, athletes, and heroes.  I think I read, George Washington Carver: Boy Scientist by Augusta Stevenson at least a hundred times.  While a professor at the Tuskegee Institute, Carver built his laboratory out of ordinary items wherever he could find them.  I tried my best to build my own home laboratory, so I could be just like George Washington Carver.  The fact that my favorite food growing up was peanut butter and George Washington Carver made all kinds of things (not just food) out of peanuts probably helped him to be my childhood idol.  His level of innovation and ingenuity in order to help him fulfill the teaching mission for his students is a great example for leaders, even by today's standards.

3. Master Chief Carl Brashear:

"It's not a sin to get knocked down; it's a sin to stay down."

I first learned about Master Chief Brashear while watching the movie, Men of Honor, starring Cuba Gooding, Jr and Robert De Niro.  Master Chief Brashear was a U.S. Navy diver shortly after the Navy became desegregated.  Master Chief Brashear is a great example of passion, dedication, and commitment to a goal.  He overcame a number of challenges, including discrimination and outright racism to become the first African American Navy diver.  He rose to the rank of Master Diver (the highest) in 1970, despite having his left leg amputated following an accident (during a salvage operation that has come to be known as the Palomares incident) in 1966.  He served for an additional nine years before retiring in 1979.  

4. Nelson Mandela:

"I learned that courage was not the absence of fear, but the triumph over it."

There are a number of civil rights leaders that I have read about and admired throughout my lifetime.  The late Nelson Mandela (who incidentally was one of the main characters in my earlier list of movies about leadership, the 2009 film Invictus starring Matt Damon, as Francois Pienaar and Morgan Freeman, as the South African President Mandela).  Nelson Mandela served as President of South Africa from 1994 to 1999, but before that he spent over 27 years in prison for speaking out against apartheid.  During his lifetime, Mandela received over 250 honors, including the Nobel Peace Prize and the U.S. Presidential Medal of Freedom.  To this day, he is held in deep respect by the people of South Africa, where he is affectionaly known by his Thembu clan name, Madiba and described as the "Father of the Nation."  His 1994 autobiography, Long Walk to Freedom is incredible and should be required reading for leaders!

5. Maya Angelou:

"I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel."

It's only been within the past couple of years that I have come to appreciate and enjoy poetry.  The late American poet and civil rights activist, Maya Angelou, is a personal favorite.  Last year, I read the first of her series of seven autobiographies, I Know Why the Caged Bird Sings which tells the story of her life up until age 17 years.  I have posted previously about a few of her poems (see Still I Rise, We are more alike my friends..., and Masks) , as her words of wisdom serve as an inspiration to us all.

"Good leaders never stop learning."  If you are not learning from the leaders of the past, then how do you think you can lead others towards the future?  

A few of history's greatest leaders

 After my last post (Twelve O'Clock High), one of my co-workers pointed out the fact that not a single movie on my list of great leadership movies had a female lead.  I quickly thanked my co-worker for calling me out, apologized, and admitted my male centric view of leadership.  As my co-worker pointed out, there has been a "women's leadership gap" throughout history.  Despite the fact that women account for 50.8% of the U.S. population, they make up only 24% of the members of Congress, 18% of governors, and only 23% of the mayors of the 100 largest American cities.  And there still has yet to be a female President (even though a female won the majority of the popular vote in the last Presidential election).  

Perhaps more disturbing is Hollywood's treatment of women in leadership positions.  Female characters in positions of leadership in the movies are four times more likely to appear nude compared to their male counterparts.  Men are twice as likely to be portrayed in leadership roles compared to women, and even when male characters have twice as many lines as female characters.  The simple fact is that top grossing films are distorting our views of women as leaders.  

As my family knows all too well, my movie selections are fairly limited to those about military history or sports. Regardless, I want to correct my mistake and list some of the female leaders that have inspired me the most.

1. Mother Teresa:

"If you can't feed a hundred people, then feed just one."  

Mother Teresa was honored in the Roman Catholic Church as Saint Teresa of Calcutta.  She was the founder of the Missionaries of Charity, a religious congregation that to this day manages homes for people who are dying of HIV/AIDS, leprosy, and tuberculosis.  The congregation also runs orphanages, schools, mobile health care clinics, and soup kitchens all around the world.  The members of the congregation take vows of chastity, poverty, obedience, and a fourth vow - to give "wholehearted free service to the poorest of the poor."

2.  Rear Admiral Grace Hopper:

"The most dangerous phrase in the language is, "We've always done it this way."

Admiral Hopper was an American computer scientist who is perhaps best known for popularizing the concept of machine-independent programming languages, and her work led directly to the development of COBOL, an early programming language that is still used today (for the record, it was never one of my favorite languages to use).  She remained on active duty in the Navy well beyond the mandatory age of retirement by special approval of Congress.  When she retired (at age 79 years), she was the oldest active duty commissioned officer in the Navy, and her retirement ceremony was held on board the USS Constitution, the oldest commissioned ship in the Navy.

3.  Marie Curie:

"Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less."

Marie Curie was one of the first scientists that I learned about when I was a young boy.  She was the first woman to win a Nobel Prize (1903 Nobel Prize in Physics for the discovery of radioactivity), the first person (and only woman) to win the Nobel Prize twice, and the only person to win a Nobel Prize in two different fields (1911 Nobel Prize in Chemistry for the discovery of the elements, polonium and radium).  She was the matriarch of perhaps the greatest scientific family ever known.  In addition to her two Nobel Prizes, her husband Pierre was also awarded the 1903 Nobel Prize, her daughter Irene Joliot-Curie won the 1935 Nobel Prize in Chemistry with her husband Frederic Joliot-Curie, and the husband of her second daughter, Henry Labouisse, was the director of UNICEF and accepted the 1965 Nobel Peace Prize on the organization's behalf.

4.  Mary Edwards Walker :

“You must come to terms with the reality that nothing outside ourselves, be it people or things is actually responsible for our happiness.”

Dr. Mary Edwards Walker was an American abolitionist, prohibitionist, and one of the first female surgeons in the United States.  She is the only woman to be awarded the Congressional Medal of Honor, the nation's highest military decoration, for her efforts to treat the wounded during the Civil War.

5.  Eleanor Roosevelt:

"You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, ‘I lived through this horror. I can take the next thing that comes along.’ You must do the thing you think you cannot do."

Eleanor Roosevelt served as the First Lady of the United States from 1933-1945.  She later served as the U.S. Delegate to the United Nations, leading President Harry Truman to call her, the "First Lady of the World."  She was a passionate advocate for human rights and a great leader during one of the most difficult periods in American history.

These five women were great leaders that inspire all of us to this day.  I have heard that there is a new movie on the life of Marie Curie - I am planning to watch it so I can diversify my list!

Stay tuned for some more greatest leaders in American history in my next post.

12 O'Clock High

Way back on Leadership Reverie post #2 ("What can we learn about leadership from a movie?"), I talked about one of my all-time favorite movies, Gettysburg, which is based on the 1974 historical novel, The Killer Angels by the late Michael Shaara.  The movie is a Masters class lesson in leadership, which I suppose is one of the reasons that I enjoy watching it over and over again.  As it turns out, you can actually learn a lot about leadership from the movies.  I can think of several excellent movies or series that I've personally found to be instructive.  Here are a few, in no particular order:

1. Invictus, the 2009 film starring Matt Damon and Morgan Freeman that tells the story of how South Africa won the 1995 Rugby World Cup, which was held in South Africa shortly after the end of apartheid.

2. Band of Brothers, a 2001 HBO television series that tells the story of the men of Easy Company, a101st Airborne Infantry company during the European Theater of World War II.

3. The Bridge on the River Kwai, an epic movie filmed in 1957, starring Sir Alec Guiness and William Holden, that tells the story of a group of American and British soldiers held in a Japanese prison camp during the Pacific Theater of World War II.

4. Apollo 13, the absolutely amazing story of the astronauts of the doomed space mission, Apollo 13, starring Tom Hanks, Bill Paxton, Ed Harris, Kevin Bacon, and Gary Sinise.

5. McFarland, USA, a 2015 movie not too many people have heard of that stars Kevin Costner as a high school cross country coach.

6. Hoosiers, the 1986 movie that tells the story of a rural high school basketball team that goes on to win the Indiana High School Basketball State Championship.

All of these movies have great teaching points on how to be a leader, and they are all really great stories too. If I had to pick just one movie on leadership though, hands down it would have to be the 1949 movie, Twelve O'Clock High, starring Gregory Peck.  The movie's lessons on leadership are so powerful, in fact, that the U.S. Navy has used it in some of its leadership courses for officers (that's actually how I came to know of the movie in the first place - we had to watch the movie during my Officer Indoctrination School in one of our classes called "Military Leadership").  Many leadership experts have called it the definitive movie on leadership.  

The movie takes place at a U.S. Air Force base in England during World War II.  Gregory Peck plays Brigadier General Frank Savage, a tough, no nonsense kind of leader who takes over a rag-tag bomber squadron whose former commanding officer was both popular and much loved by his men, but unfortunately not very effective as a leader.  Savage takes over a squadron whose combat readiness and effectiveness has reached the bottom depths.  It's a great story of an amazing turnaround.  By the end of the movie (I won't spoil it), Savage has turned the squadron into one of the most effective outfits in the entire Air Force.

Here are a few tidbits on leadership from the movie:

1. Accountability is everything - When Savage first encounters the squadron, men are not wearing their uniforms properly, security guards aren't asking for identification, and the men are spending most of their time at the bar.  Discipline is lax.  Savage restores accountability and discipline, which goes a long way to establishing his role as the leader of the unit.

2. Develop leaders - Savage takes a personal interest in building a core group of leaders.  He takes one of the most talented pilots and places him in charge of one of the worst air crews.  Under the pilot's new leadership, the air crew becomes one of the strongest in the squadron.

3. Promote excellence - Leaders inadvertently encourage behaviors that they tolerate.  Accept nothing but excellence.  And when you see examples of excellence, reward it.

4. "Communicate the why" - A leader's job is to create a vision and make sure that everyone understands and works towards that vision.

5. Leadership is lonely - The former commanding officer became too close to his men and would refuse to ask them to take risks.  While that is certainly admirable, it doesn't work too well during a war.  As a leader, you can certainly be friendly to everyone, but you can't be everyone's friend.  There is a distance that should separate leaders from their teams.

It's an amazing movie, and I encourage you all to watch it!  You will pick up a lot of lessons on leadership, and the story is definitely worth the investment of time too.

"Making lemonade when you're given lemons is leadership..."

 I am currently reading a book by the late NFL Hall of Fame football coach, Bill Walsh entitled "The Score Takes Care Of Itself".  Bill Walsh is perhaps best known as the 3x Super Bowl winning head coach of the San Francisco 49ers and inventor of what is now commonly referred to as the "West Coast offense".  In the book, Walsh writes, "Making lemonade when you're given lemons is leadership; making lemonade when you don't have any lemons is great leadership."  By every measure then, Bill Walsh was not only a great NFL football coach, but he was also a great leader.

Let me explain.  When Walsh took over as head coach of the 49ers in 1979, the team was in complete disarray.  During the two previous seasons, the 49ers win-loss record had been 7-23.  Overall, the team had never appeared in the Super Bowl or won a NFL championship.  Unfortunately, the team finished 2-14 in Walsh's first season as head coach.  They finished 6-10 the following season, but the team had started to show some evidence of improvement (several of the team's losses had been close).  Most importantly, Walsh benched his quarterback, Steve DeBerg in favor of future Hall of Famer, Joe Montana.  The next year, the team would win the NFC championship (defeating the Dallas Cowboys in a game memorable for Dwight Clark's last second touchdown reception, known as "The Catch") and go on to win Super Bowl XVI over the Cincinnati Bengals.  It was an incredible turnaround!  By the time that Coach Walsh stepped down as head coach after the 1988 season, his 49ers team had won three Super Bowls (XVI, XIX, and XXIII) .  More important, under his leadership, the 49ers built a dynasty that would go on to win five Super Bowls with a number of future NFL Hall of Famers.  Making lemonade out of lemons?  One could certainly argue that the team that Walsh took over had very few lemons - he made lemonade out of nothing!

There is perhaps no better example of making lemonade when you don't have lemons than the genesis of the "West Coast offense."  As the story goes, Bill Walsh was working as an assistant coach for the legendary Cincinnati Bengals coach, Paul Brown in the early 1970's.  The Bengals were short on talent (sound familiar?), particularly on the offensive side of the football.  Their quarterback, Virgil Carter, was quick, mobile, and accurate, but he lacked the kind of arm strength to make the deep passes that were popular at the time.  The Bengals also lacked the kind of running game that was necessary for the typical offense in use by most NFL teams at the time.  So what do you do in this situation?  You improvise and adapt!  Bill Walsh designed an offense that would take advantage of the Bengals' key strengths - speed and agility.  Rather than relying upon long, deep passes to fast wide receivers ("vertical" offense), he designed an offense where running backs, tight ends, and wide receivers would run short, tight passing routes that his quarterback Virgil Carter could easily throw.  He also stretched out the passing routes horizontally to take advantage of the width of the field.  

The rest, as they say, is history.  Defenses were slow to adapt and respond to this new type of offensive strategy.  The Bengals were successful with the new strategy and started winning.  When Paul Brown retired from coaching, the Bengals named Bill Johnson as the new head coach, so Bill Walsh left to join the San Diego Chargers coaching staff.  After spending some time in San Diego, he became the head coach for Stanford University, where the team's opponents found out how hard it was to defend the "West Coast offense."  Walsh was soon asked to become the head coach for the San Francisco 49ers, largely as a result of the success of his new offense.

Making lemonade out of a bunch of lemons - that's what Bill Walsh did with his "West Coast offense."  That's leadership!  Designing a strategy to fit the unique skills and assets of your team is exactly what great leaders do.

"We rely upon your ability...You know what to do"

 There is perhaps no greater underdog story than that of the American Revolution.  Great Britain had more money, more experience, and more resources than the fledgling United States, and yet the United States would eventually defeat the British forces and win their independence.  As one of many examples, American naval commander John Paul Jones helped lead the Continental Navy against the most powerful Navy in the world, at that time.  His actions against the Royal Navy earned him an international reputation and the title, "Father of the American Navy."  While his exploits aboard the  Bonhomme Richard are well-known ("I have not yet begun to fight!"), Jones found his earliest success aboard the USS Ranger.  The American commissioners in Paris (Benjamin Franklin, Silas Deane, and Arthur Lee) issued the following orders to Jones on January 16, 1778:

After equipping the Ranger in the best manner for the cruise you propose, that you proceed with her in the manner you shall judge best for distressing the enemies of the United States, by sea or otherwise, consistent with the laws of war, and the terms of your commission...We rely on your ability, as well as your zeal to serve the United States, and therefore do not give you particular instructions as to your operations.

The American commissioners were giving Jones an unbelievable degree of latitude ("...do not give you particular instructions as to your operations").  In other words, go out and do what you think best to complete your mission.  Certainly the nature of naval warfare in the 18th century required this degree of decentralized command, as ships typically operated far from land and were frequently out of communication from leaders for days or even weeks at a time.  In Jones' case, the naval leadership above him in rank could even be across the other side of the Atlantic Ocean!  

As B.A. Friedman and Olivia Garard recently wrote, "John Paul Jones had a mission, the means with which to accomplish it, and the leeway to decide how best to pursue it.  That freedom was not infinite.  It was bounded by the 'laws of war' and 'the terms of his commission.'  Jones knew what to do, what not to do, and had space within which to make decisions."

But that was all a long time ago.  With advances in communication technology, were naval captains in later wars given the same degree of latitude?  The answer to this question is "yes"!  Fast forward to the Battle of Cape St. George during World War II.  A destroyer squadron led by then Captain Arleigh Burke (whose nickname was "31 Knot" Burke) was ordered by his commanding officer, Admiral William "Bull" Halsey to intercept a five-ship Japanese convoy consisting of transport ships and their destroyer escorts.  Here was Admiral Halsey's order:

Thirty-one Knot Burke Get Athwart The Buka-Rabaul Evacuation Line About 35 Miles West of Buka.  If No Enemy Contacts By 0300, Come South to Refuel Same Place.  If Enemy Contacted You Know What To Do.

Again, no specific instructions on what to do when Captain Burke's destroyer squadron contacted the enemy.  Just a simple, "You know what to do."  Halsey trusted that Burke would do the right thing.  And that is exactly what happened - even today, the U.S. Naval War College describes the battle as "An almost perfect surface action."

Here we find two examples of the High Reliability Organization principle of "Deference to Expertise".  Essentially, High Reliability Organizations (HRO's) push decisionmaking to the experts on the front lines.  Here, the leaders that are closest to the action are the ones that are empowered with making time-sensitive decisions.  They are expected to make decisions with certain ground rules and within the boundaries specified by their immediate supervisors.  

"Deference to expertise" is a principle common to most high-performing organizations, and the principle itself is known by a variety of names, including Commander's Intent, Mission-type tactics, and auftragstaktik (a form of "deference expertise used by the German Army in World Wars I and II).  In my opinion, perhaps the best description of "deference to expertise" comes from two phrases used in John Paul Jones' orders and Arleigh Burke's orders - "We rely upon your ability...you know what to do."  In other words, "I trust that I can rely upon you to make the right decision for the good of the organization and our mission."

Lost Luggage

"Please raise your hand if you never check your luggage when you fly," I asked the audience.

Several hands went up immediately.  I motioned towards a woman in the audience and asked, "Why don't you check your luggage?"

"Because I have to pay $25-50 each time,” she replied.

"Fair enough.  But you can afford that right?"  The woman nodded in response, so I asked again, "So, if it's not about the money, what is the real reason that you never check your luggage?"

"I am afraid the airline will lose it," she replied.

"Has that ever happened to you?" I asked.

"Maybe once a few years ago," the woman replied.

While the exact sequence of questions probably didn't happen exactly as I described (the story is apocryphal), I have often asked a similar question whenever I have been talking to groups about patient safety with a similar response.  As it turns out, according to a survey of more than 570 airline passengers conducted a few years ago, about 20% of passengers always carry on their luggage (nearly 30% of passengers say they always check their luggage).  Considering that over 4.5 billion passengers flew in 2019, that means that 900 million passsengers every year carry on their luggage.  When you further consider that, at least according to the Bureau of Transportation Statistics, the 15 largest airlines in the United States make about $3.5 billion in total revenue from baggage handling fees, there is clearly a lost opportunity for additional revenue by encouraging more passengers to check their luggage.

So how often do airlines really lose your luggage?  In general, it happens about 2 to 3 times per 1,000 passengers.  An obvious question follows - why accept this rate of failure when it represents a potentially significant opportunity to generate additional revenue?  Indeed, 20% of all passengers absolutely refuse to accept this degree of failure rate, and close to 50% will carry on their luggage depending upon their specific circumstances (say, for example, if a passenger has a tight connections - and doesn't want to take a chance on the airlines losing the luggage in transfer!).

If a significant percentage of the general public refuses to accept a failure rate on the order of 2-3 per 1,000 for something as minor (at least in the grand spectrum of things) as lost luggage, then why are we in health care willing to accept this kind of failure rate for things that are arguably much more important, i.e. things that have an impact on patients' lives?  Actually, when you compare apples to apples (passenger deaths due to airline accidents versus patient safety-related deaths), there's really no comparison!  Every time that you fly, there is a 1 in 3 million risk of dying.  Compare that statistic to a 1 in 300 chance of dying from a preventable medical error!   

Multiple studies report that 10% of patients suffer from an adverse event while in the hospital, and approximately half of these adverse events are preventable!  Let's take a look at some more specific rates of failure compared to the rate of lost luggage (these statistics are from the National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015):

Catheter-associated Urinary Tract Infections:  8.2 per 1,000 hospital discharges

Falls:   6.7 per 1,000 hospital discharges

Pressure Ulcers:   36.3 per 1,000 hospital discharges

Central Line associated Bloodstream Infections (CLABSI): 0.05 per 1,000 hospital discharges

Surgical Site Infections:   2.5 per 1,000 hospital discharges

Hospital-acquired C. difficile infection:   3.1 per 1,000 discharges

Overall, with the notable exception of central line infections, hospitals compare quite poorly to airlines and their "lost luggage" failure rate.  This kind of failure rate is not acceptable for airline passengers, and it shouldn't be acceptable for patients admitted to our hospitals either!  More concerning, despite several years of hard work and focused attention on these hospital-acquired conditions, we aren't really getting that much better.  Clearly we have some work to do.  Perhaps we need a change in focus - or at least a change in attitude.

Even now, some of these conditions are viewed by many as "the cost of doing business" - if your hospital is taking care of really sick patients with a lot of chronic conditions, your hospital is going to experience these kinds of hospital-acquired conditions.  That attitude MUST change!  There are enough examples of hospitals who drive down their rates of these conditions and continue to take care of the sickest of the sick patients.  

There are approaches that we can take.  I've written a lot of posts in the past on high reliability organizations.  We need to learn from other health care organizations that are on the journey to high reliability, as well as industries outside of health care (like commercial aviation - but looking at their accident rate and not the lost luggage rate).  I wholeheartedly believe that this is the right kind of approach, and we will talk more about high reliability organizations in the next post!

"Diabolical dictators or capable commanders?"

At the end of my last post, What style of leadership works best...", I stated that I would talk about a study about "diabolical dictators and capable commanders" that was published in the journal, Leadership Quarterly in 2015.  It's an interesting study, because it tries to answer the question of which leadership style is more effective - the authoritarian, autocratic, "diabolical dictator" type of leadership or the democratic, supportive, "capable commander" type.  

The concept of power frequently comes up in discussions about leadership.  "Power" is generally defined as the ability of an individual (usually the leader, but not always) to exercise some form of control over another individual or a group of individuals.  Whereas power deals primarily with control and influence, leadership requires the ability to not only create a vision, but also to motivate another individual or a group of individuals to work towards achieving the leader's vision.  Certainly, the ability to motivate others requires a certain degree of credibility and trust.  Power, on the other hand, does not depend on any personal attributes but rather requires the individual to have some position of authority.  

Just as there are different styles of leadership (as we discussed in the last post - authoritarian or autocratic, democratic, and laissez-faire), there are different types of power - coercive, legitimate, reward, expert, and referent.  Coercive power occurs when individuals have the power to threaten, by for example, demoting or firing an employee, giving a poor performance review, or cutting someone's pay.  Reward power is essentially the opposite - power conveyed by an individual's ability to reward through pay raises, promotions, or good performance reviews.  Legitimate power is the type of power that comes with position - for example, being the leader of a team, the director of a group, or the chief executive of an organization.  These first three types of power are formalized and generally handed to a leader.  The next two types of power have more to do with personal characteristics.  For example, expert power is exactly what it sounds like - the power that an individual has due to their experience, knowledge, and skills.  Referent power is the kind of power that comes when an individual is greatly respected and trusted.  It's important to recognize that individuals don't need to be leaders to have power (see especially expert power and referent power).  However, it is difficult to be a leader without having some form of power, be it formal power or personal power.  

Power can be centralized or decentralized.  Here is where power and style leadership intersect!  Authoritarian, or autocratic leadership usually centralizes or concentrates power in a single dominant individual (the "diabolical dictator" referenced in the study we are about to discuss).  With democratic leadership, on the other hand, power is less centralized (and in a way, the leader is the one conferring power on the group by allowing them to play a role in making decisions).   

One can certainly see some benefits to the centralized power of authoritarian leadership.  For example, the members of the group definitely know at all times who is "in charge."  There is a clear hierarchy with this style of leadership, which can be beneficial in some circumstances.  Conversely, authoritarian leadership may also negatively impact group performance.  For example, authoritarian leaders can be negative for team morale.  So, which is it?

In the "Diabolical Dictators or Capable Commanders?" study, teams from 60 retail (in this case, from the finance industry) outlets (225 employees and their managers) were prospectively studied using validated measures of team dynamics and leadership.  Overall team performance was determined by dividing the total sales per day by the number of customers per day.  Here are the results.  When there were no power struggles on the team (different individuals or factions competing for power), authoritarian or autocratic leaders were actually beneficial, in terms of overall team performance.  Conversely, when there were power struggles, the authoritarian leadership style only worsened these power struggles further, causing overall team performance to suffer.  

The results seem counterintuitive at first.  The investigators surmised that authoritarian leadership is "only effective in establishing a clear chain of command which helps members make sense of the world, allocate resources, and interact in a safe and efficient manner when team members accept the existing power hierarchy in the team and do not engage in power struggles."  When power struggles exist, the existing hierarchy is disrupted and team performance deteriorates.  

More studies such as this one are needed.  Studies exploring team dynamics and leadership styles in health care would be particularly useful.  Regardless, the key point to remember is that effective leaders flex between the different leadership styles, depending upon the needs of the team.  In the end, it's likely that no one leadership style will be universally applicable in all situations.  

As the management guru, Warren Benis once said, "Leadership is the wise use of power."  Similarly, Winston Churchill said, "Leadership is the intelligent use of power." The best leaders optimally utilize their base of power to accomplish the tasks at hand.

What style of leadership works best? It depends on the problem at hand...

It's an age-old question that is as timeless as the tides.  Is one particular leadership style preferable to another, regardless of the particular situation?  Most studies would suggest that the best leaders will exercise the three basic (there are more, but these will suffice for now) leadership styles - authoritarian, democratic, and laissez-faire - depending upon the context of the situation.  Note that authoritarian leaders rule their groups, while democratic leaders try to include everyone in the decision-making process.  With authoritarians, "my way or the highway" is the rule of the day.  Democratic leaders, on the other hand, let consensus decide.  Laissez-faire leaders simply let the group run by itself.

When most individuals think of authoritarian leadership, they will undoubtedly make references to leadership in the military.  They would be incorrect in doing so.  I have read a number of books on military history in general, as well as several biographies of military leaders throughout history.  Combined with my own anecdotal experience while serving in the Navy, I would have to say that the best military leaders are the ones who can easily flip back and forth among the three different leadership styles mentioned above, again depending upon the specific needs of the situation.  

I have been particularly interested by the relatively recent writings of Keith Grint (see a review of his theory of leadership here).  Dr. Grint is Professor Emeritus of Leadership at Warwick University, and he generally breaks down leadership into three categories - Command, Management, and Leadership.  "Command" is basically the authoritarian style of leadership, while "Leadership" is more like the democratic style.  However, "Management" is not laissez-faire but sits more intermediate between "Command" and "Leadership."  

It's quite an elegant solution to an age-old question, at least in my opinion.  

Dr. Grint goes on to define Critical, Tame, and Wicked problems.  "Tame" problems are those that, while complicated have probably occurred before.  The solution to "Tame" problems is fairly straightforward.  Here, "Management" probably works best.  

"Wicked" problems are both complicated and complex and probably have never occurred before.  The solution to "Wicked" problems aren't readily apparent, and they may be as complicated and complex as the problem itself.  Here, the "Leadership" style that leverages the expertise of the group fits the best.

Finally, when you think of "Critical" problems, think of a crisis.  The world is falling apart all around you, everyone is looking to you to tell them what to do.  In other words, with "Critical" problems, "Command" is the best approach.

There's more to discuss here.  Next time, we will review some of the evidence that supports at least some of these arguments.  Stay tuned for "Diabolical Dictators or Capable Commanders" next time.